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Agenda Packet CITY OF CUPERTINO AGENDA lop C U P E RTI N O PARKS AND RECREATION COMMISSION This will be a teleconference meeting without a physical location. Thursday, April 1, 2021 7:00 PM This Meeting Will Be Televised TELECONFERENCE / PUBLIC PARTICIPATION INFORMATION TO HELP STOP THE SPREAD OF COVID-19 In accordance with Governor Newsom's Executive Order No-29-20, this will be a teleconference meeting without a physical location to help stop the spread of COVID-19. Members of the public wishing to observe the meeting may do so in one of the following ways: 1) Tune to Comcast Channel 26 and AT&T U-Verse Channel 99 on your TV. 2) The meeting will also be streamed live on and online at www.Cupertino.org/youtube and www.Cupertino.org/webcast Members of the public wishing comment on an item on the agenda may do so in the following ways: 1) E-mail comments by 5:00 p.m. on Thursday, April 1st to the Commission at parksandrecreationcommission@cupertino.org. These e-mail comments will be received by the commission members before the meeting and posted to the City's website after the meeting. 2) E-mail comments during the times for public comment during the meeting to the Commission at parksandrecreationcommission@cupertino.org. The staff liaison will read the emails into the record, and display any attachments on the screen, for up to 3 minutes (subject to the Chair's discretion to shorten time for public comments). Members of the public that wish to share a document must email parksandrecreationcommission@cupertino.org prior to speaking. 3) Teleconferencing Instructions Members of the public may observe the teleconference meeting or provide oral public comments as follows: Page 1 Parks and Recreation Commission Agenda April 1,2021 Oral public comments will be accepted during the teleconference meeting. Comments may be made during "oral communications" for matters not on the agenda, and during the public comment period for each agenda item. To address the Commission, click on the link below to register in advance and access the meeting: Online Please click the link below to join the webinar: https:Hcityofcupertino.zoom.us/webinar/register/WN_yLFhbCedTfS_4Fi6UhxDDw Phone Dial 669-900-6833, enter Webinar ID: 929 2359 7464 (Type *9 to raise hand to speak) Unregistered participants will be called on by the last four digits of their phone number. Or an H.323/SIP room system: H.323: 162.255.37.11 (US West) 162.255.36.11 (US East) 213.19.144.110 (Amsterdam Netherlands) 213.244.140.110 (Germany) 103.122.166.55 (Australia Sydney) 103.122.167.55 (Australia Melbourne) 69.174.57.160 (Canada Toronto) 65.39.152.160 (Canada Vancouver) Meeting ID: 929 2359 7464 SIP: 92923597464@zoomcrc.com After registering, you will receive a confirmation email containing information about joining the webinar. Please read the following instructions carefully: 1. You can directly download the teleconference software or connect to the meeting in your internet browser. If you are using your browser, make sure you are using a current and up-to-date browser: Chrome 30+, Firefox 27+, Microsoft Edge 12+, Safari 7+. Certain functionality may be disabled in older browsers, including Internet Explorer. 2. You will be asked to enter an email address and a name, followed by an email with instructions on how to connect to the meeting. Your email address will not be disclosed to the public. If you wish to make an oral public comment but do not wish to provide your name,you may enter "Cupertino Resident" or similar designation. Page 2 Parks and Recreation Commission Agenda April 1,2021 3. When the Chair calls for the item on which you wish to speak, click on "raise hand." Speakers will be notified shortly before they are called to speak. 4. When called,please limit your remarks to the time allotted and the specific agenda topic. In compliance with the Americans with Disabilities Act (ADA), anyone who is planning to attend this teleconference meeting who is visually or hearing impaired or has any disability that needs special assistance should call the City Clerk's Office at 408-777-3223, at least 48 hours in advance of the meeting to arrange for assistance. In addition, upon request, in advance, by a person with a disability, meeting agendas and writings distributed for the meeting that are public records will be made available in the appropriate alternative format. CALL TO ORDER ROLL CALL CEREMONIAL MATTERS AND PRESENTATIONS 1. Subject: Demonstration of the New Online Tennis Reservation System. Recommended Action: Receive a demonstration of the new online tennis reservation system. APPROVAL OF MINUTES 2. Subject: Meeting Minutes for the March 24, 2021 Parks and Recreation Commission Special Meeting. Recommended Action: Review and approve the minutes for the March 24, 2021 Parks and Recreation Commission special meeting. A-Draft Minutes POSTPONEMENTS ORAL COMMUNICATIONS This portion of the meeting is reserved for persons wishing to address the Commission on any matter within the jurisdiction of the Commission and not on the agenda. Speakers are limited to three (3) minutes. In most cases, State law will prohibit the Commission from making any decisions with respect to a matter not on the agenda. WRITTEN COMMUNICATIONS OLD BUSINESS Page 3 Parks and Recreation Commission Agenda April 1,2021 3. Subject: Fiscal Year 2021-22 Community Funding Application Evaluations and Recommendation to City Council. Recommended Action: Receive staff report, allow for clarifying questions, receive public comment and close item, receive Commissioner scoring for the Fiscal Year 2021-22 community funding applications. Staff Report A-Community Funding Applications&Staff Evaluation Forms B-Commissioner Community Funding Evaluation Form C-Evaluation Totals Form D-Community Funding Applications Summary 4. Subject: Commission Initiated Discussion Regarding the Rancho Rinconada Recreation and Park District's Community Outreach Efforts. Recommended Action: Discuss Rancho Rinconada Recreation and Park District's Community Outreach Efforts. 5. Subject: Fiscal Year 2021-22 Community Funding Application Evaluations and Recommendation to City Council- Continued. Recommended Action: Continuation of Item #3 for the purposes of consideration of evaluations, and decisions to provide funding recommendation for Council. Staff Report A-Community Funding Applications&Staff Evaluation Forms B-Commissioner Community Funding Evaluation Form C-Evaluation Totals Form D-Community Funding Applications Summary NEW BUSINESS STAFF AND COMMISSION REPORTS 6. Subject: Monthly Update Reports. Recommended Action: Receive monthly update reports from the Director of Parks and Recreation and commissioners. COMMISSIONER ATTENDANCE AT UPCOMING MEETINGS AND EVENTS FUTURE AGENDA SETTING ADJOURNMENT In compliance with the Americans with Disabilities Act (ADA), anyone who is planning to attend this teleconference meeting who is visually or hearing impaired or has any disability that needs special assistance should call the City Clerk's Office at 408-777-3223, at least 48 hours in advance of the meeting to arrange for assistance. In addition, upon request, in advance, by a person with a disability, meeting agendas and writings distributed for the meeting that are public records will be made available Page 4 Parks and Recreation Commission Agenda April 1,2021 in the appropriate alternative format. Any writings or documents provided to a majority of the members after publication of the agenda will be made available for public inspection. Please contact the City Clerk's Office in City Hall located at 10300 Torre Avenue during normal business hours. IMPORTANT NOTICE: Please be advised that pursuant to Cupertino Municipal Code 2.08.100 written communications sent to the Cupertino City Council, Commissioners or City staff concerning a matter on the agenda are included as supplemental material to the agendized item. These written communications are accessible to the public through the City's website and kept in packet archives. You are hereby admonished not to include any personal or private information in written communications to the City that you do not wish to make public; doing so shall constitute a waiver of any privacy rights you may have on the information provided to the City. Members of the public are entitled to address the members concerning any item that is described in the notice or agenda for this meeting, before or during consideration of that item. If you wish to address the members on any other item not on the agenda, you may do so during the public comment. Page 5 CITY OF CUPERTINO CUPERTINO Legislation Text File M 21-9068, Version: 1 Subject: Demonstration of the New Online Tennis Reservation System. Receive a demonstration of the new online tennis reservation system. CITY OF CUPERTINO Page 1 of 1 Printed on 4/1/2021 powered by LegistarTM CITY OF CUPERTINO CUPERTINO Legislation Text File#: 21-9069, Version: 1 Subject: Meeting Minutes for the March 24, 2021 Parks and Recreation Commission Special Meeting. Review and approve the minutes for the March 24, 2021 Parks and Recreation Commission special meeting. CITY OF CUPERTINO Page 1 of 1 Printed on 4/1/2021 powered by LegistarTM CITY OF CITY OF CUPERTINO is PARKS AND RECREATION COMMISSION Teleconference Special Meeting CUPERTINO Wednesday, March 24, 2021 6:00 PM DRAFT MINUTES CALL TO ORDER Chair Stanek called the meeting to order at 6:00p.m. via remote teleconference. ROLL CALL Commissioners present: Carol Stanek, Xiangchen Xu, Gopal Kumarappan, Neesha Tambe, Sashikala Begur Commissioners absent: None Staff present: Joanne Magrini, Rachelle Sander, Whitney Zeller, Alex Corbalis CEREMONIAL MATTERS AND PRESENTATIONS APPROVAL OF MINUTES 1. Subject: Meeting Minutes for the March 4, 2021 Parks and Recreation Commission Meeting. Recommended Action: Review and approve the minutes for the March 4, 2021 Parks and Recreation Commission meeting. Commissioner Tambe motioned to approve the minutes. Commissioner Kumarappan seconded the motion. Motion carried with 5 votes yes. POSTPONEMENTS None ORAL COMMUNICATIONS None WRITTEN COMMUNICATIONS None OLD BUSINESS 2. Subject: Final Review and Prioritization of the Parks and Recreation Strategic Plan Park Amenity Improvements. Recommended Action: Conduct the final review and prioritization of the Parks and Recreation Strategic Plan Park Amenity Improvements. Recreation Coordinator, Alex Corbalis, reviewed the item and the Commission's recommendations from previous meetings. Chair Stanek noted that the picnic tables and benches at Three Oaks Park were not reflective of the Commission's recommendation. Staff noted they would review data again and highlight any discrepancies between meeting minutes and the data sheet and noted that the $3,500 for a BBQ should be added at Creekside park, not Portal Park. Staff mentioned that they would move forward with pickleball striping at Memorial Park as a trial before implementing it at other parks recommended by the Commission. Commissioner Tambe asked if we could record pickleball striping at Varian and Monta Vista Parks as a low priority. Chair Stanek recommended reviewing the data again for low priority recommendations from the Commission, noting benches and picnic tables at Jollyman Park, Creekside Park benches, Portal Park shade, and Canyon Oak Park shade. Community Member Lisa Warren provided public comment. Commissioner Tambe recommended approving the first two $200k for the 2020-21 and 2021-22 fiscal years, in the order that Public Works deems correct, as well as implementing opportunities for nature play and exercise equipment in year two. She recommended communicating that specialty items, such as the BBQ for the picnic area and outdoor table tennis be prioritized, followed by the other recommended amenities, and that further conversation be facilitated regarding nature play and outdoor exercise equipment for year two of funding. Commissioner Xu commented that shade trees should be prioritized for year one, noting that they will take a while to grow and provide shade. Director Magrini summarized that we would provide funding recommendations to Public Works, noting prioritization of pickleball striping, outdoor table tennis and BBQ at Creekside Park and will inform the Commission of the determined first year of funding. She noted that staff can return to the Commission to have a further conversation on nature play and outdoor exercise equipment, and inclusive elements for consideration. Commissioner Begur requested that the Commission receive a list of the low-priority items. 3. Subject: Quarterly Update on the Parks and Recreation Commission Fiscal Year 2020- 21 Work Program and Ongoing Items. Recommended Action: Receive a quarterly update on the Parks and Recreation Commission Fiscal Year 2020-21 Work Program and ongoing items. Director of Parks and Recreation,Joanne Magrini, provided a presentation on the item. 4. Subject: Evaluation Process for the fiscal Year 2021-22 Community Funding Grant Program. Recommended Action: Review the evaluation process for the Fiscal Year 2021-22 Community Funding Grant Program. Administrative Assistant, Whitney Zeller, provided a presentation on the item. Commissioner Tambe requested that the Commissioner's evaluation sheets be posted following the meeting. Commissioner Tambe recommended providing a way to allow commissioners to digitally submit their scores live during the meeting. She noted that she appreciates the opportunities for public comment and commission discussion. Commissioner Kumarappan agreed that there should be an opportunity for commissioners to digitally submit their scores live during the meeting, rather than verbally, to avoid influencing each other's scores. Chair Stanek noted that the Commission will need to discuss eligibility and that the Commission should be prepared to score all applications. Commissioner Kumarappan recommended discussing eligibility prior to ranking organizations. Commissioner Tambe noted she was comfortable providing rankings for all applications and discussing eligibility one by one. Chair Stanek clarified that all Commissioners should be prepared to provide scores for all organizations. NEW BUSINESS None STAFF AND COMMISSION REPORTS 5. Subject: Monthly Update Reports Recommended Action: Receive monthly update reports from the director of Parks and Recreation and commissioners. Director Magrini noted the County moved to the orange tier and would provide an update at the next meeting. Commissioner Begur noted she attended the Mayor's meeting and would provide an update at the next meeting. Commissioner Xu noted she received a flyer from Rancho Rinconada Recreation and Park District regarding their community outreach meetings. Commissioner Kumarappan noted that he had received the flyer from Rancho Rinconada Recreation and Park District as well. Commissioner Tambe recommended adding the Rancho Rinconada Recreation and Park District public outreach to a future agenda for discussion. Commissioner Kumarappan seconded. Chair Stanek attended the Walk by Cupertino meeting where David Stillman from Public Works provided updates on trails and bike lanes. COMMISSIONER ATTENDANCE AT UPCOMING MEETINGS AND EVENTS FUTURE AGENDA SETTING Director Magrini reviewed the anticipated agenda items for the April 1 meeting. Commissioner Tambe motioned to add Rancho Rinconada Recreation and Park District public outreach as a future agenda item for discussion. Commissioner Kumarappan seconded the motion. Commissioner Tambe added that she would like the Commission to compose a letter or notice to City Council regarding the item. Community member Jennifer Griffin provided public comment and expressed concern with the City's consideration of acquiring the Rancho Rinconada Recreation and Park District. The Commission confirmed a special meeting will be held on April 8 at 5:30 p.m. ADJOURNMENT Chair Stanek adjourned the meeting at 7:39 p.m. to the April 1, 2021 meeting at 7 p.m. Respectfully submitted, Whitney Zeller, Administrative Assistant Parks &Recreation Department Minutes approved at the regular meeting 0 CITY OF CUPERTINO CUPERTINO Legislation Text File M 21-9070, Version: 1 Sum: Fiscal Year 2021-22 Community Funding Application Evaluations and Recommendation to City Council. Receive staff report, allow for clarifying questions, receive public comment and close item, receive Commissioner scoring for the Fiscal Year 2021-22 community funding applications. CITY OF CUPERTINO Page 1 of 1 Printed on 4/1/2021 powered by LegistarTM CITY OF PARKS AND RECREATION DEPARTMENT QUINLAN COMMUNITY CENTER 10185 NORTH STELLING ROAD • CUPERTINO, CA 95014-5732 TELEPHONE: (408) 777-3120 • FAX: (408) 777-1305 CUPERTINO CUPERTINO.ORG PARKS AND RECREATION COMMISSION STAFF REPORT Meeting: April 1, 2021 Subject Fiscal Year 2021-22 Community Funding Application Evaluations and Recommendation to City Council. Recommended Action Receive staff report, allow for clarifying questions, receive public comment and close item, receive Commissioner scoring for the Fiscal Year 2021-22 community funding applications. Discussion Background At the March 4 Parks and Recreation Commission meeting, the 17 applicants for the Fiscal Year (FY) 2021-22 Community Funding Grant Program had the opportunity to attend, provide additional information on their request, and answer any clarifying questions from Commissioners. Prior to the meeting, staff reviewed all submitted applications for completeness and eligibility, determined by compliance to the Community Funding Policy. The Commission was provided with all applications as well as the staff evaluation forms (Attachment A). Evaluation Process At the April 1 regular meeting, the Commission will facilitate the evaluation process and will provide a funding recommendation to City Council. After receiving public comment on the item, there will be a brief recess to allow for the Commissioners to complete their evaluation form (Attachment B) before providing their total out of 100 for each application. Staff will take the totals from each Commissioner and compile them into the evaluation totals form (Attachment C). The Commission will proceed with other business on the agenda to allow staff time to organize the data provided by the Commissioners. When the Commission returns to the item, there will be another opportunity for public comment, specifically regarding evaluations. The Commission will continue to discussion of the data utilizing the evaluation totals form, will have the opportunity to adjust rankings accordingly, and will determine a funding recommendation for City Council. Eligibility Staff concluded that seven applications fully met eligibility requirements and ten applications were pending eligibility, requiring further consideration by the Commission. This is reflected in the Community Funding Applications Summary (Attachment D). Final eligibility of applications will be determined by the Commission during the evaluation process. The Commission will be able to review the scores during the evaluation process and discuss eligibility further as a group. Sustainability Impact No sustainability impact. Fiscal Impact The Commission will review application evaluations and provide a recommendation regarding funding to City Council for final approval. Prepared by: Whitney Zeller, Administrative Assistant Reviewed by: Joanne Magrini, Director of Parks and Recreation Approved for Submission by: Joanne Magrini, Director of Parks and Recreation Attachments: A-Community Funding Applications & Staff Evaluation Forms B-Commissioner Community Funding Evaluation Form C-Evaluation Totals Form D-Community Funding Applications Summary City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Comrnunity Funding Grant in the past` Q Yes * No If, Yes,when? SECTION 1: CONTACT INFORMATION Legal blame of Valkyrie Robotics Organization: Web Address: Oupertlinlc� alfc .ar Mailing Address: City: Zip, 95014 Phone President/Executive Marcus Plutowski Title: Executive Director Director; Email: mare us @vaJkyrierobotics.corn Telephone Number: Contact Person: Ashwin Rajesh Title: President of Business Operations Email Address: ashwin.rajesh@a valkyrierobotics.comTelephone Number: l-f'Ri)f IT IN 0F2MAT10N 501(c)(3)? Q Yes Q No Year Established 2016 Federal Tax ID Fiscal Sponsor Name: Valk rie Robotics Fiscal Sponsor Address; City: San .lose Zip: 95125 Phone, `Fii ! • i-'.' i;Jia1 IN: [li'Prl?=5i ,i;'-j Total Organization Budget: $60,000 Total # of Board Members: 3 Total #of staff: 7 Total # of Volunteers: 20 Mission Statement: Through a variety of educational programs in science, technology, engineering, and mathematics ('STEM') targeted at 6th-12th grade students in California's southern Bay Area, Valkyrie Robotics seeks to strengthen the students of today with the skills and experience necessary for the industries of tomorrow_ Brief Description of Organization: Valkyrie Robotics is based in the heart of Silicon Valley, the cradle for modern technology. Yet even here, the demand for STEM programs far outpaces the supply; most local robotics teams are based out of a single school, where hundreds of students may compete for too few a number of slots, and many others offer no such team at all. In contrast, Valkyrie accepts students from any school, race, gender, or financial background, and seeks to serve those students of which no other organization serves. Through our competitive and educational programs,we give students hands-on experience in all aspects of robotics and engineering. We also hold a variety of educational events at faires, parks, museums throughout the flay Area to give back to the community that has helped us become the team we are today. Each year we seek to expand our operations to serve more students, whether through holding new outreach events,expanding our existing programs, or founding new ones wholesale. Brief Description of Services Provided: Valkyrie Robotics revolves around the titularly-named team 299 which consists of 30 to 40 high school students competing in the FIRST Robotics Competition (FRC), Each year, all FRC teams are challenged to build robots at the industrial-level within a one-to-two month time frame designed to complete specific objectives at regional competitions. Students part of Valkyrie's FRC team have the opportunity to explore all facets of the engineering process including, design, manufacturing, electrical and software. The team only by creating an environment for students to acquire hard skills, but also by emphasizing the importance of soft skills such as teamwork and collaboration which are vital in a professional workplace setting. In addition, Valkyrie offers a summer program called Valkyrie Advance far middle school students who are not yet of age to join the FRC team. Students learn the fundarnentals of robotics through VEX IQ robotics,which focuses on the basics of hardware and software. SECTION 4: GRANT REQUESTS 1. Program/Project/Event Name: Mini-Robot Competition 2. Date(s)and/or duration of prograMproject/event(it applicable):July 2021 -August 2021 3.Total program/projecNevent budget: $5,000 4. Requested Amount: $3,000 Percent of total program/projectfevent budget: 60% S. ProgmrNPmject projected income: $0 Remarriage of your organization's projected income: 0% 6.Type of Request: 0 Capital Improvement ❑Program Support 0 Event OOne-time project 0 Other: 7.This grant will fund a(n): 0 Existing program/projecUevent established in(year) 12 New program/project/event 8. Describe the purpose of requested funds and the services that will be provided: The Mini RobotCompetition aims to replicate engineering-related experience as much as possible while still staying safe during the current pandemic.The project will involve teams of three to four Cupertino students tasked with designing, manufacturing,wiring,and coding a robot that completes tasks as part of a central challenge presented to them during the project kickoff. Funds from this grant will go directly towards project supplies and safety measures.Supplies include Arduir o microcontrollers and electrical components for a programmable robot control system,as well as 3D printers and plastic for the fabdcalion of mechanical pans in a manner that does not require any power tools or machinery In a dedicated workshop. Funds for safety measures include masks and sanitization for students to work and transport tools and supplies to one another safely. Safely glasses will also be provided to ensure that students working with tools and components are adequately protected. 9. Please provide a line item breakdown of how the funds will be used in the categories below. If a category is not applicable, put$0: Admin Staff J$3.00 MaterialslE uI ment Entertainment Room/Venue Rental Other Professional Services Other otal 10. Explain how the request aligns to City mission and values: As an organization, Valkyrie Robotics alms to create an environment which fosters education, innovation,and collaboration within its members. During the COVID-49 pandemic,Valkyrie hopes to continue inspiring students to pursue their interests in the field of STEM.These students have had little opportunity to socialize with friends and peers in meaningful and educational ways,especially due to the fact that most extracu nicular activities have been cancelled of moved to, unfortunately,a less-effective virtual setting. Valkyrie, however, believes that Teaming and safety are net necessarily mutually exclusive.The most important goal of the Mini-Robot Competition is to provide opportunities for students to team and grow as individuals as much as possible and as safely as possible. 11. Describe how the progran✓projecUevent fills a community need.Who identified this need?What other similar project/program/event exists to serve Cupertino residents?How is your proposed projecUprogram/event unique from similar projects/progmms/events or how do you collaborate to avoid duplication? Due to the current pandemic, many local FIRST robotics teams have been unable to participate in this year's competition and provide adequate looming opportunities to students as a result.Valkyrie, as one of these teams, aims to fill this lack of robotics involvement by hosting a program that parallels the FIRST robotics experience in a safe and responsible manner. The Mini-Robot Competition is similar to the Tech Challenge hosted annually by the Tech Interactive,where teams of Bay Area students are challenged to build devices that fulfill specific challenges. The Mini-Robot Competition Is unique because it, as well as the resources it provides,will be free-of-charge to participants. In addition,the event alms to create a more diverse learning experience. While the Tech Challenge focuses more on mechanical and electrical engineering, the Mini-Robot Competition will also allow teams to explore how software can be used to control hardware components In uniquely complex ways. 12.Who will be served by this grant? This grant,which will directly fund the Mini-Robot Competition project, will serve 3040 middle and high school students from across Cupertino, a)Number of individuals total: 40 b)Number of Cupertino residents: 40 - c)Particular community groups: The event is dedicated towards middle-school and highschool students situated in Cupertino. d)Will the program/projecbevent be available to the entire communitylpublic or are there any eligibility criteria? The event will be open to middle school and high school students from across Cupertino who wish to participate and will be capped to 40 participants on a first-come,first-serve signup basis. e)Will there be a charge or fee for the progren✓projecbevenl(if applicable) There is no charge or fee for participants. f)What outreach methods does your organization use to promote the program/projectmvent (if applicable)? Valkyrie Robotics will not use outreach methods to promote this event. 13. Describe how the funs will be used to benefit or impact the Cupertino community: As mentioned above, the goal of the Mini-Robot Competition Is to safely and effectively provide an meaningfully educational robotics experience to students across Cupertino in the effort to inspire them to pursue their interests in the field of STEM. Using the funds from this grant,the project can teach a variety of skill sets across mechanical, electrical and software engineering, hopefully allowing students to realize their passions and possibly even set themselves on a path for college and the world beyond. The project also emphasizes the importance of soft skills such as teamwork and organization.Working in teams of three or four, students are solely responsible for assigning, scheduling,and managing their work in order to meet the deadlines set by the competition. Not only does the Mini-Robot Competition aim to help develop students' passions for STEM, but to equip them with the experience, skills, and knowledge they need to be successful in any career. 14. Demonstrate that the member implementing and managing the program/projectfevent have adequate experience: Valkyrie Robotics has adequate experience managing events similar to the Mini-Robot Competition due to its history of sponsoring a FIRST Robotics Competition (FRC)team through several years of robot builds. FRC involves industrial-level engineering in the fields of design, manufacturing,electrical and software; as a result, Valkyrie has experience implementing standard workshop and tool safety procedures. In contrast, the Mini-Robot Competition requires only the use of small repair tools for assembly purposes; all manufacturing of robots will involve 3D printers rather than metal or wood machinery.Additionally,the Arduino electrical system eliminates the necessity for potentially dangerous electrical procedures such as crimping and soldering. Valkyrie Robotics also has several adult mentors with more than 40 combined years of robotics experience.These mentors will supervise teams during the competition, offering guidance virtually and in-person only ff absolutely necessary. 15. How will success of the program/projectlevent be measured?: The success of the Mini-Robot Competition event will depend upon the experience and educational value that students will have gained,which will be measured in three ways. First,at the end of competition,teams will lest their robots against the obstacles and challenges provided to them during the project kickoff. If teams can successfully build robots that complete these challenges, it will be clear that team members will have put in the effort to acquire and apply new skills in an effective and collaborative manner.The second method of measurement will be the supplies and techniques that teams will have used to develop their robots.This will allow us to know haw students have explored the resources available to them and applied their newfound knowledge towards implementing and utilizing these resources. Finally, the project will have a closing survey where students will be asked a variety of questions that will gauge how much they gained from this experience. 16. Will more than 75% of the requested funds go towards direct service costs versus administrative coats? OO Yes 0 No 17,Will you collaborate with other organizations to deliver the prograrNprojectlevent funded by this grant? If so, which organizations? Valkyrie Robotics does not plan to collaborate with other organizations when hosting the Mini-Robot Competition. 18. If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants,please describe this support: 19. Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of prograntlprojectlevent (e.g.fee waivers)? If so, please describe this anticipated support: Valkyrie Robotics does not anticipate receiving additional support from the City of Cupertino. 20. If you are a multi-jurisdictional organization,describe any funding requested from other agencies/organizations in regards to this program/projectlevent request. Indicate whether the funding was granted, denied,or is still pending: 21. How would you fund the program/projectlevent if you do not receive the requested funding?: Valkyrie would seek alternative methods of funding for this event. such as through grant requests from local companies or through fundraising campaigns in partnership with local establishments,although funding from these sources is obviously not guaranteed. ECTION 5: PRIOR FUNDING 1. If you received a Community Funding Grant In prior years, indicate the amounts for each year and describe how those funds were used: 2. If you received a Community Funding Grant last year: a.Please provide a line item breakdown of how the Community Funding Grant was used last year in the categories below. If a category is not applicable, put$0: I.Admin Staff it. Materials/Equipment iii. Entertainment iv. Room/Venue Rental Other Professional Services . Other Total $ b.Who was served by the grant last year? I. Number of individuals total: ii. Number of Cupertino residents: Ill. Particular community groups iv.Was the program/project/event available to the entire community/public or are there any eligibility criteria? v.Was there a charge or fee for the program/projectlevent(if applicable)? vi.What outreach methods did your organization use to promote the prograMproject/evenl(if applicable)? c.Was the program/project/evenl successful? Please indicate how success was measured: 3. Please indicate any additional funding received last year from other sources and provide your financial statement if available: Attachments: Attach your financial statment, and any other helpful information about your project. Program Manager Signature President of Business Operations Date Signed 02/01/2021 Valkyrie Robotics (NEW) Eligibility Checklist (staff use only) Eligibility YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X p ro gr am/p r of e c t/event Identify how the funds will be used to benefit the Cupertino X community Be awarded only once per project X For specific needs,not on going,operational costs X Have more than 75%of the requested funds allocated for direct X service costs versus administrative costs Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only submit one application NA Proceeds generated from the funded activity may only be used for NA the conducted activity admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved NA by Parks and Recreation Commission City of Cupertino Fiscal Year 2021 Community Funding Grant Apglicatiun Have you ever received a City of Cupertino Community Funding Grant in the past? 0 Yes * No If, Yes, when? Legal Name of Organization: Tian Hong Foundation Web Address: owww.l[anhon foundation.org Mailing Address:City: rtino Zip: 95014 Phone: PresidentlExecutive Director:Zuxin U Title: CEO Email: Telephone Number: Contact Person: Susan Shi Title: CFO& COO Email Address: Telephone Number: 501(c)(3)? * Yes 0 No Year Established 2011 Federal Tax 1D Fiscal Sponsor Name: Susan Shi Fiscal Sponsor Address.- City: u pertfno Zip: 95014 Phone: -1 cTION 3- 0.RCAN1Z)'%:r1nrr 11-1,-al NIATION Total Organization Budget: $20,000 Total #of Board Members: 2 Total #of staff: 2 Total # of Volunteers: 0 Mission Statement: Our mission is to facilitate cross cultural communication, education, and arts & cultural exchange. Our programs aim tc improve public health, happiness, and appreciation of arts from various cultural backgrounds. Brief Description of Organization: Tian Hong Foundation is a non-profit private operating foundation established in California in 2011, Our mission is to facilitate cross cultural communication, education, and arts &cultural exchange. Our programs aim to improve public health, happiness, and appreciation of arts from various cultural backgrounds. Brief Description of Services Provided: Host free public seminars on cross cultural art appreciation; Sponsor and co-manage cultural dance performance shows and provide free tickets to multi-cultural audience; Host annual cross cultural youth art contest; Produce free content promoting positive thinking and poetic approach to life, with highlights on happiness, cultural heritage and arts appreciation. C 1ION L.: GRANT r �ti .'i 1: 1. Program/Project/Event Name: 2021 Youth Art Contest(Nature and Me) 2. Date(s) and/or duration of program/project/event(if applicable):April - Sep 3. Total program/projectlevent budget: $6.000 4. Requested Amount: $3,000 Percent of total program/projectlevent budget: 50% 5. Program/Project projected income: $0 Percentage of your organization's projected income: 6. Type of Request: ❑Capital Improvement a Program Support ❑Event ❑One-time project CD Other: 7. This grant will fund a(n): 0 Existing program/project/event;established in 20181 ❑ New program/projecNevent 8. Describe the purpose of requested funds and the services that will be provided: Tian Hong foundation has been hosting cross cultural art contest for young artists since 2018. With the success in 2020 with unprecedented number of contestants and winners in the contest with main theme of'Love, Hope and Collective Humanity',we hope to expand the program even further to deepen influence in the community.2021's main theme will be'Nature and Me'.Contestants will be asked to submit original art creations(including all media) to depict beautiful nature and the relationship between nature and the artist. If we get support from City of Cupertino, more emphasis will be put into encouraging young artists in Cupertino to participate and depict the beautiful environment of the City, hence build higher awareness around environmental protection and preservation. 9.Please provide a line item breakdown of how the funds will be used in the categories below. If a category is not Iot licable, ut$0Admin Staff $Materials/Equipment $500 Entertainment $ RoonJVenue Rental $0Other Professional Services $0 ther cash awards for contest winners $2,500 al $3,00 10. Explain how the request aligns to City mission and values: To support City of Cupertino Green Earth initiatives and raise awareness among young generations for a beautiful City environment. 11. Describe how the progran/project/event fills a community need.Who identified this need?What other similar project(programlevent exists to serve Cupertino residents?How is your proposed project/program/event unique from similar projects/programslevents or how do you collaborate to avoid duplication? Tan Hong foundation initiated this program.We have hosted cross cultural youth an contest for three years now, and in 2021, our main theme will be'Nature and Me', which triggered this move to apply for community grant funding,in order to potentially join farces to further promote Green Earth initiative. 12.Who will be served by this grant? young artists(at or under age of 21)who submit their original artworks to reflect the theme of the contest; as well as general community,with whom the content of the artworks will be shared. a)Number of individuals total: 200 b)Number of Cupertino residents: 100 c)Particular community groups: young artists(at or under age of 21) d)Will the program/project/event be available to the entire community/public or are mere any eligibility criteria? young artists(at or under age of 21) e)Will there be a charge or fee far the program/project/event(if applicable) no charge,free participation f)What outreach methods does your organization use to promote me prograMprojecHevent(if applicable)? pacebook ads,Tan Hong website broadcast, Emetic to Tan Hang art community, Linked In post, etc. 13. Describe how the funds will be used to benefit or impact the Cupertino community: This funding will be specifically allocated to award young contestants from Cupertino, including cash awards, ad materials award, annual artwork calendar, etc. Tan Hong will have separate budget to award contestants from other areas. 14. Demonstrate that the member implementing and managing the program/projectlevenl have adequate experience: Refer to our website www.tianhongfoundatlon.org for our track record in hosting the annual youth art contest.We also attached the 2020 contest process doc and summary slide deck in this application. Below please also review Tian Hong 2020 Cross Cultural Youth Art Contest Winners Announcement Video on Youtube: heps://www.youtube.com/watch?v=11 OgiRTX9u4 15. How will success of the program/project/event be measured?: number of participants,quality of the artworks submitted,feedback from the community 16.Will more than 75% of the requested funds go towards direct service costs versus administrative costs? ® Yes O No 17.Will you collaborate with other organizations to deliver the prograi/project/e tent funded by this grant? If so, which organizations? not yet 18, If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants,please describe this support: n/a, this is the first time we apply for funding 19. Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of program/project/event (e.g.fee waivers)? If so, please describe this anticipated support: no 20. If you are a multi-jurisdictional organization, describe any funding requested from other agencieslorganizations in regards to this program/project/event request. Indicate whether the funding was granted,denied, or is still pending: we 21. How would you fund the program/projectlevent if you do not receive the requested funding?: Tian Hong foundation will still fund the program to a smaller scale if we do not receive the requested funding from City of Cupertino. However,with additional funding, we will be able to put more emphasis on the young artist community in Cupertino,which we love dearly as our hometown.With more funding, we will also be able to expand influence by more advertising and offer more creative awards to contestants. SECTION 5: PRIOR FUNDING 1. If you received a Community Funding Grant in prior years, indicate the amounts for each year and describe how those funds were used: n/a 21f you received a Community Funding Grant lost year: a. Please provide a line item breakdown of how the Community Funding Grant was used last year in the categories below. If a category is not applicable. put$0: i.Admin Staff ll. Materials/Equipment iii. Entertainment iv. Roonri Rental .Other Professional Services A.Other Total S0 b.Who was served by the grant last year? i. Number of individuals total. ii. Number of Cupertino residents: iii. Particular community groups iv.Was the program/project/event available to the entire community/public or are there any eligibility criteria? v.Was there a charge or fee for the program/project/event(if applicable)? A.What outreach methods did your organization use to promote the program/projectrevent(if applicable)? c. Was the program/project/event successful?Please indicate how success was measured: 3. Please indicate any additional funding received last year from other sources and provide your financial statement i i �, �'� I 1 i ;, �`; I 1 1 4 1 ra, .�outh Art Goriest or9 2020 Gross Gu1tu NUmapity Love , Tsar N d CO leetiv e Hope an A'Jg 28th, 2020 Summary • We have received submissions from 97 contestants with a total of 131 artworks (31 of them from age group 4-1211 o0 of them from age group 13-21). • Young artists have demonstrated great passion and talent in their artworks reflecting this year's main theme - Love, Hope and Collective Humanity. Many have also included real life stories, thiserva very ions a difficult wishes in their artist statements as they g of 2020, • Congratulations to all who have won awards and all who have participated with passion and creativity! We are so proud of you! • ' Group I • Name Age Artwork Name Space X, • - World, One Dream Lingfei Coco Truong 10 (color pencil, marker) Artist statement: "Space X brings people to the space. I hope one day I can travel to other planet with my loved family and friends } a • ' Group 4-12 - 1 st Place Award Age Group 4-12 - 2nd Place Award Name Age Artwork Name Simran Dandiwal 10 Integration not Segregation (color pencil) `0 r >,. G5 A., ,I ° t?� Artist statement. "My picture is about compassion and equality. All human beings are equal and should not be discriminated." n a_ SuiN G0.Pi201J � Y µ `' 5 Eb 0.F 6nT10N Age Group 4-12 - 2nd Place Award Name Age Artwork Name One Drop of Water Jiahao Jasper Truong 6 (color pencil, marker) Artist statement. '7 hope people around the world can save lives of a • free and animal, also save water as _ these are important for our beautiful n planet." rim ' _d • ' Group • Place Awards Name Age Artwork Name Simran D. Boa Ryoo 10 All of OurTree House YYf iM Yit Y �l �� ♦fl if if h �� I �� i Yiil ff ii '� Age Group 4-12 - 3rd Place Awards Name Age Artwork Name Suhaansie Watada 6 united We Stand Ruby Martinez 10 Tree of Peacefulness and Eternity Ahaanya Karthikeyan 6 collective Humanity Tree VZI ` � IF® IONy � Ii o = cr ru Age Group 4- 12 - Encouragement Awards Name Age Artwork Name Scarlett Yu 8 Love Nature Srinidhi Annepu 11 Peacock Ved Navaneet 9 Portrait of Martin Luther King Lingfei Coco Truong 10 Making Face Shield for Heroes Sameeha Soora 12 Super Heroes around Us Jordyn Wong 7 Love, Hope and Collective Humanity Koen Helmuth 7 Make Our World a Better Place Sravya Nittala 8 Trees of Happiness Alisa Ilic 10 Rose of Love Kloe Helmuth 10 Flower Dream Age Group 4- 12 - Thank you for your participation ! Name Age Artwork Name Aiendri Guha 7 Love, Hope and Collective Humanity (Warli Art) Alisa Ilic 10 Basket of Hope Dhruv Vyas 7 Waiting for the Dawn Dhruv Vyas 7 Charmed Devotees of Lord Krishna Elisa Solis-Herrera 4 Flowers Elise Solis-Herrera 4 Red Jiahao Jasper Truong 6 My Play date Kristine Le 7 Two Cultures Unite Riley Wong 10 Love, Hope and Collective Humanity Sahab Dandiwal 9 Equality for All Srinidhi Annepu 11 Radha Krishna Age Group 13-21 - 1 st Place Award Name Age Artwork Name Dior Chen 17 Perpetuity (graphite) Artist statement: "Regardless of the struggles humans encounter, they relentlessly battle against all odds in hopes ,.. ,. of ultimately attaining harmony and Prosperity" t Age Group 3-21 - 1 st Place Award Name Age Artwork Name Jessica I Have a Dream Lin 20 (collage, acrylic paint on cardboard) Artist statement. "inspired by the Black Lives Matter movement .. it reflects contemporary social issues. The main subject is a young African-American girl who wants to dismiss the stereotypes of African-American women." Age Group 13-21 - 2nd Place Award Name Age Artwork Name Helen Ngo 16 ATouch in Time (acrylic paint) ir y � r, a. z . Age Group 13-21 - 2nd Place Award Name Age Artwork Name Carolyn Nguyen 17 To Mend Artist Statement. "Being able to _. 'mend' these masks and distribute them with love and care 'mends' AWONO�N the community even during these tough tames." Age Group 13-21 - 3rd Place Awards Name Age Artwork Name Hannah Cha 17 Find the Light Chloe Wang 16 The Angel Around Us Sunny Zhou 17 Let's All Dine Together Age Group 13-21 - 3rd Place Awards Name Age Artwork Name Treina Le 18 Love of Humanity Czarina Gfindro 18 A World of Beauty and Unity Emily Orozco 16 Love is the Seed of Hope uA XW L- ura9a'�1e�t P�ards En�O �+ 13'21 P9P�y ' GrOup myorKNa e Age 16MasKedTo9ether e $e rte Together Ne v en N5° 13 es oS Humana Apat er\aeTran �pGtrm ver Be Opp pur Nands a The�o Melissa onl16 he\Garden of Narmorry Jenny `0 s So a prness En dy Ninh The Sacrifice r H 4 ph\oe Waa.D a2 Al gi th_m DeskT °l onted Em Y pr030° Al pOnnecredProte° EVAa Geronlmo Age Group 13-21 - Thank you for your Participation ! lowd- Name Aga Armmi Name Name Age Artwork Name Name Age Aral Name name Age Artwork Name Robot Tacassum Lo'Mg Band Erzerage Christian Chang 14 Beauy,d Hurranlly Knew Mai Our 20 Renimmumes 3h9eraj 15 Love ACrm9 Me Gbha Nan Jim i3 Ma µasp Full d Lon& Armom Lee 19 Retvie M Henry, Chnimme Chang 14 LMMent or Our AArew Khi KWle 13 Happiness Sarz Ya 1]A o Communion pore y Cindy2Aou 10 gal V4Anrms Sa2A Ym 17 Reiglws SyrcNony, Amy Ym 19 ANowpW Kamm Nguyen I] ANamAmnia Airy YaO I9 ANewous Dane Hu 10 Humanity in Panda Larro'sa Wsguez 15 AMONKS Love Serena Clan i] ASpmloRove Ana Pretiado 101nEl Vbmen Daphne Chang IB &ry buying Wnl/ Lesley Mzm 1] RatedgUp Serena Chan iJ wouni lLove Indigenous Serena Liu ONLIau Tertge Anurn Crossed Chang 16 For under nee LPskyMwn 9 Hanok Balhetl in Light L'na Lee 16 our 34en th A Sofia Rum P Connected grtllik Amended 13 PMPding HumanRy Sofia Rim 17 Before and AuthorneelaMw O Huv1 DomainNgrryen IT VnmeaRA Huma nlly LY 1a Lea I6 Por6ssa Jasmine Sophia Materials 13 Blver 4 als si ave Angela Vex uez tC AIIMwnd Us EIIa Gemnmo IJ The PPaddtile OrisM Luiu Federalp,in CulNre Pastures 16 Lane Under X-ray WearAngola Vuyuez 14 Blm]Sis@rs EIk KM IS The N4001n My EyesYOU are Man Main,the Lulu m Feanda SWW E n l Owen 18 Earth.the SEtn AplkaAgaMe1 15 AcepMnm EmityB 16 MomeMsd Love partGes 18 Vnlhtl AOea Hanson fJ Crab Fishing TMary Royer iJ Belo Me Fall Emits RemaMex 18 Tift PipcP Megan lrewan 14 PddC Al BimnO Ple[a3 Aorta H¢maa 17 ARM hWrran EmiN N'NF 17 TEI Megan Kawtua L Rbndds AllArWntl TManY AY 21 Rod SMnO my Fate Ben Our 19 GMtluction biro universe IS Euphona Megan Kawada 14 Lima Far A Lang Am Tina Wong 17 Unque Bed Uni Ben Wr 19 Wnbr Flower MPiAn Bebney 16 NYIIFkeer Twirled" 17 Transfer Brad Idea lverwva le The Night Con Be OWry-Bmugli 19 Vn Danced Freely JGe Gana 10 was BelongTigmer hibnry 18 The fiaindow nMkn Tows BUGwatl 20 The Fm's Light BnmeV Sun 16 Cxkan Surs Jenlvkr Long 17 Premises nadlne misman0 IB Swimming in Cities Tow Bu]aaard 20 Le9k Chaung';Us N ether Maddy" el he Premium Trish Le 10 Together Wa Am One BnOAeV bun 10 Away vnIn WONs Jenny Lu IB Hope for a"at Tomorrow Mal Lee 17 Asian Supermarket Fish XxhiOLord 20 For Everyone CaJeV Capable 18 Tp 0¢aT Oa USApad JingGng Lee 18 FMy Oovn ggssu Ly 17 CWgea Zssi lieng(Anne) Ceze Yu 15 Tree1 Jingong Lee 16 AJoumq Back spend MCdomm ComYg lyMer for the Zhu 14 Scrams dAKepiercm CMoe None 18 Tgress,She Jiymn Han 16 Together the Bdng Sheing 16 Grmler Sam 2ceV Lei 13 The FNure is BrgM Tian Hong 2020 Youth Art Contest Judge Panel 144r� Danuta Hutchins - Artist & Linguist Farzi R. - Artist Susan Shi - Art Lover, Tian Hong Foundation CFO & COO Kj O r nd rgra�u�a��Ons , C° .hank y°u Qu,�g Eoopdatic�rat Exchange Tian Oong and Cuft� getter Society via A Tian Hong Foundation 2020 Cross Cultural Youth Art Contest - Love, Hope and Collective Humanity General process steps: • Decide on a main theme for the art contest • Arrange overall contest timeline- submission due date, award announcement date, etc. • Invite /confirm judge panel • Prepare contest posters and Advertisements on Facebook&Tian Hong website, Wechat, Linked In, etc. • Prepare contest score sheets and share with judge panel • Review& score all submissions • Conductjudge panel discussion and review meeting • Decide on final award winners' list • Award winners' announcement (Email to contestants, Tian Hong website, Facebook/ Linked In/WeChat) • Award distribution (via Paypal in 2020, or by check mail) &certificate distribution (via email in 2020) • Compile complete list of award winner Paypal transactions (including judge's gift $200 each), print out transaction list from Paypal, for future tax record keeping purposes Key 2020 dates Apr 10th, 2020- Public announcement on Tian Hong website, Message to Tian Hang art community email distribution list, Facebook Post and Wechat launch; May 31st, 2020- Launch last-month marketing campaign on Facebook, Email reminder sent to Tian Hong Art community Jul 31st, 2020-all artworks submission due Aug 28th, 2020-awards announcement Sep 7th, 2020-All awards/certificates electronically sent to recipients (reception R Award localion' DApertino Ouir)lan Communitv Canter. Social P•.Qom '10185 1"1 Stelling Ind, Cupertino. CA 950,14 Capacity- 80) Main theme: Love, Hope and Collective Humanity. Awards will be presented to outstanding original artworks that capture or manifest moments, thoughts or visions of the subject theme. Unique artworks that reflect different cultural influences and promote love, kindness and beauty are encouraged. Eligibility artists with age of 21 or under; originally designed and self completed artwork(s) in all media, including drawings, paintings, photographs, graphic design, sculpture, etc. maximum 2 entries per artist. This year, we will be dividing our artists into two age groups to encourage broader participation: #of Award per Age group:4- 12 contestants contestant 1 st place 1 $300 2nd place 2 $150 3rd place 5 $50 encouragement 10 $20 Age group: 13-21 1 st place 1 $500 2nd place 2 $250 3rd place 5 $100 encouragement 10 $20 Registration and submission of entries: Print, complete and sign the entry form here and email to tianhongfoundation@amail.com together with all digital images of artworks by Jul 31st, 2020. We accept high quality digital images (digital art files that are 300 DPI or better. We can work with Jpg, .tif, .gif, or .psd file, or high quality PDFs.) Award announcement: All awards will be announced by Aug 31st, 2020. Awards will be electronically sent via PayPal to the recipients; certificates will be sent to email addresses as provided. Insurance and photographs: Tian Hong Foundation assumes the privilege of sharing digital images of works entered into the contest for the purpose of education, documentation or public sharing. Detailed to-do list- 1. Initial scheme of program outline-416/2020 2. Finish competition entry form-week of 4/6/2020 3. Design a one-page marketing poster- week of 4/6/2020 4. Public launch of program via Facebook&WeChat,TianHong website and TianHong art community email distribution list-4/10/2020 done! 5. Form judge panel a. Susan Shi-confirmed b. Canto H.- confirmed c. Farzi R.-confirmed 6, Marketing of the program a. Tian Hong website-done b. Referrals from existing attendees c. Facebook i. May 15th-Jul 15th Last 60 day Post Boost on Facebook d. Foundation email distribution list-sent 4110 a. Eventbrite past attendees L WeChat-for Chinese community 2018 Federal Private Foundation Tax Summary page 1 201:8 Federal Private Foundation Tax Summary Page 2 Tian Hong Foundation Tian Hong Fcundafion Ong 201.7 Diff 2018 207E Diff REVENUE PER BOOKS ANUSTED NET INCOME EXPENSES Dividends & interest from seenrities- .-. 15,383 80.516 S,46S adjusted net income 15.677 10,171 5,506 Net gate (3wss} - noninv. assets/d_sp ., C.,75Y 4i52S 235 Ocher income.. . . , _05 ii7 -€a CRARMASLE PURPOSES DISBURSEMENTS Accow'ting fees. ........ .... ... .. .. .. 1,140 0 1,140 _etal,reve-ue. ..-.: .:... .....:... ..... : ...... 20,848 15,155 3,C89 Otfser expenses. 12,730 13,770 -11060 Ma? .afxe:atingladministraz!ve exp, . 13,S50 13,770 80 EXPENSES PER BOOKS AccirdntLng fees, 1,!40 0 1,140 Contributions, gifts, grants paid,, ..- :,28Q 422 ala Taxes 309 345 -43 Depreciation- 474 543 T?7s Total expenses and disaorsements.. ,. =5A90 14„92 898 Other expe6SSS..---. .; 12,713 13,770 -1,060 Total operating:fadninistrative exp, . .... ?4.62S 14,764 -?36 NET ASSETS OR FUND BALANCES Corrr Wtlons, gifts, grants. paid . ..-,. 1,340 422 ale Net assetsAfu-nd bab._ at beg, or year.... 110,014 310,441 -27 Excess of revenue, over expenses ........ 4,584 -2't 5,007 Tarsi expenses.. . ..:................ .. 15,868 35,18E 622 Het assetslbod bat. at eacd of year .. 314,594 310,014 4,980 Excess of revemit- ever expenses 4,ss0 -27 5,607 NET NVES}�yMENTREVENUE Dividends & interest from se=rit+es.,,,,. 15,981 30,51E 5,465 Capital gain net inroame...... ................... 4,761 4,526 235 'otal revenue....... . ..... ..• 20,742 15,042 5,700 NErINVESTM NT EXPEN4SE5 Tay.em„ . ...... .-... 304 345 -41 ioca8 operating/administrative exp- ,.. 304 345 -43 local er_perses..,..,.. .., 304 345 -41 Net investmert income.,.,,:.,. 20>438 14,697 5174i TAX COMPUTATION' Tax on, -net dnvestmert 'income. .. 409 0 409 Tax an investment larome..... ........ 409 0 4cs PAyMEENTSAND CREDITS Total payments and etedits. ,.. ., 0 0 0 REFUND OR AMOL94T DUE Tar. due.. . .. . .. . 405 0 409 Dverpayment.: . . '. C 0 0 TAX RATES Marginal tax. -rare 0,0% 2.0% Effective talc rate..... ..,.,-'.. 2.C% 0.0-e 2.43 ADJUSTED NErINCOME REVENUE U4VIdends & jnlcereSt frow secur3t1es•. 15,981 10'si6 5:$65 ?ctal revenue.. .. . 15,521 0 is,RT51 ADJUSTED NET INCOME EXPENSES Taxes.. .. .. 304 34.5 -41 Total operating/administrative exp- 304 34S -�4.1 70rai expenses .,.,.., ... 304 345 -41 Tian Hong Foundation (NEW) Eligibility Checklist (staff use only) Eligibility YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/project/event Identify how the funds will be used to benefit the Cupertino X communi Be awarded only once per project X For specific needs,not on going,operational costs X Have more than 75%of the requested funds allocated for direct X service costs versus administrative costs Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only NA submit one application Proceeds generated from the funded activity may only be used for NA the conducted activity admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved NA by Parks and Recreation Commission City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Community Funding Grant in the past? Yes No If, Yes, when? 'mot:fi�]t•l !' EaUi! !t��i I�i�,�r�i'1,�1i l�;`s Legal Name of Organization: Discovery Counseling Center - Cupertino(DCCC) Web Address: www.m discovervcc.com Mailing Address: City: Cupertino Zip: 95014 Phone: President/Executive Director:Stanley Kuo Title: Board Director Email: Telephone Number: Contact Person: i eun Title: Program Sponsor Email Address: Telephone Number: f;i:-I ii}i1i i,+,�-yi•,I.i'I-.;i',;:;I i; -- ,� ,•i.ti,-i.i•;);, 501(c)(3)? Yes Q No Year Established 2002 Federal Tax ID Fiscal Sponsor Name: The Home of Christ Church in Cupertino Fiscal Sponsor Address: City: Cupertino Zip: 95014 Phone: Total Organization Bridget: $600,ODC Total #of Board Members: 8 Total#of staff: 50 Total #of Volunteers: 5 Mission Statement: Our mission is to live life well while exemplifying the love of Christ by being the hands and feet of Jesus. We aim to serve the community with love, gentleness, and compassion. To extend grace, teach, develop long-lasting healthy relationships with the community and each other.To lead by example while remaining humble and teachable. Expand future programs and services through telehealth, provide classes and workshops. To equip and train extraordinary health professionals to give hope, insight, and direction to the families we serve. Brief Description of Organization: Discovery Counseling Center is a 501 @(3) nonprofit faith-based organization.Although DCC is of Christian faith, staff provides service to those in the community with dignity and respect regardless of religious background or affiliation. Brief Description of Services Provided: For DCC, it is counseling services. For DCC Cupertino �DCCC), it is affordable counseling services for those in need. DCCC is sponsored by The Home of Christ Church in Cupertino's Community Fund. The goal is to make counseling services affordable to the public by subsidizing counselor's pay so they are willing to accept insurance payment, 1. Program/Project/Event Name: Affordable Counseling Services 2. Date(s)and/or duration of program/project/event(if applicable):On going. Fiscal year is calendar year. 3.Total programlprojectlevent budget: $70,200 4. Requested Amount: $7,200 Percent of total program/projectlevent budget: 10% 5. Program/Project projected income: Percentage of your organization's projected income: 0% 6.Type of Request: ❑Capital Improvement ❑Program Support ❑Event 00ne4ime project 120ther: Subsidy for 0.5 professional counselor so they can accept Insurance payment 7.This grant will fund a(n): ❑ Existing program/project/event;established in (year) 0 New progmm/projecVevent 8. Describe the purpose of requested funds and the services that will be provided: The Affordable Counseling Service(ACS)allows professional counselors who are willing to work for less can have a guaranteed based income. In the counseling field very few counselors accept private Insurance because they pay very low.The ACS program guarantees a minimum pay for the counselor who are willing to accept insurance and with the program making up to their minimum pay.The grant would allow us to hire one additional counselor 9. Please provide a line item breakdown of how the funds will be used in the categories below. If a category is not applicable, put$0: Admin Staff $ b Materials/E ui ment Entertainment RoomlVenue Rental $ Other Professional Services 0.5 counselor $7,20, Other $, Total $7,20 10. Explain how the request aligns to City mission and values: Mental health needs are great. Health insurance coverage is not enough. Most professional counselor would not accept private insurance. DCCC partnered with The Home of Christ Church in Cupertino(HOGS)to offer affordable counseling services to the community since 2016.The Community Fund from H0C5 supports DCCC's annual budget.This year DCCC launches a guaranteed pay program for its counselors in order to attract professionals to join their counseling service.The grant will allow DCCC to hire 0.5 more counselor. Counselor will accept private insurance. Subsidy will guaranteed their hourly pay even insurance pay much less.This is strictly a community service. 11.Describe how the program/project/event fills a community need.Who identified this need?What other similar pmjecf/program/event exists to serve Cupertino residents?How Is your proposed projecl/progmm/event unique from similar projects/programslevents or how do you collaborate to avoid duplication? 10%of the population has mental health issues. Many who have a need for counseling services are deterred by the high hourly rate charged by licensed counselors($130$150 per hour). Even if a person has health insurance coverage but professional counselors would not accept insurance billing.DCCC guaranteed counselors pay at $110 per hour.On average insurance pays about$60$701hr. For someone who has no Insurance,the subsidy to the counselor is much higher 12.Who will be served by this grant? Any adults, irregardless of faith,race or gender.Services are advertised on sponsors website (www.hoc5.net). a)Number of Individuals total: 5 b)Number of Cupertino residents: 2 c)Particular community groups: Anyone who has mental health Issues d)Will the program/project/event be available to the entire community/public or are there any eligibility criteria? No eligibility criteria.Anyone who seeks mental health help are welcomed.Anyone who has experienced depression,grief, trauma,emotional disorder, are welcomed. e)Will there be a charge or fee for the program/project/event(if applicable) Services are usually covered by health insurance,though they do not pay enough. DCCC guaranteeds counselors pay depending on their qualification (Licensed, Intem,Trainee, etc). If counsellee does not have insurance, they will be charged on a sliding scale based on their income.For someone who has no income, they will be charged the minimum-$15 per hour. f)What outreach methods does your organization use to promote the program/project/event(if applicable)? We advertise the services with in the H005 faith community and on its website under Community Services.About half of H005's members live In Cupertino. 13. Describe how the funds will be used to benefit or impact the Cupertino community: The fund will allow us to hire a half time professional counselor. DCCC has been offering its services since 2016. People are often referred by word of mouth. The counseling office is located in Cupertino,so is its sponsor H005. 14. Demonstrate that the member implementing and managing the prograelproject/event have adequate experience: Stanley Kuo-eoard director of Discovery Counseling Center in Morgan Hill,has years of professional counseling experience. He recruits and train counselors. He is also a licensed counselor. Bill Leung-elder at H005,was Corporate Controller for a medium sized distributor. He has many years of administrative experience. 15. How will success of the program/project/event be measured?: It will be measured by the hour of service we provide to the community. 16.Will more than 75%of the requested funds go towards direct service costs versus administrative costs? * Yes O No 17.Will you collaborate with other organizations to deliver the prograndprojeci/event funded by this grant? If so, which organizations? The Home of Christ Church in Cupertino,who has been in Cupertino for over 25 years.We plan to introduce this collaboration model to other churches so they can serve their communities. 18. If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants, please describe this support: Not applicable 19. Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of program/project/event(e.g.fee waivers)? If so, please describe this anticipated support: No 20. If you are a multi-jurisdictional organization, describe any funding requested from other agendes/organizalmns in regards to this program/project/event request. Indicate whether the funding was granted, denied, or is still pending: Not applicable 21. Haw would you fund the progmin/project/event a you do not receive the requested funding?: If we do not receive requested funding,we would have to curtail our services to 2 counselors instead of 3. SECTION 5: PRIOR FUNDING 1. If you received a Community Funding Grant in prior years,indicate the amounts for each year and describe how those funds were used: Not applicable 2.If you received a Community Funding Grant last year: a. Please provide a line item breakdown of how the Community Funding Grant was used last year in the categories below. If a caffei is not applicable, put$0: 1I. Admin Staff Matenals/E ui ment Entertainment RoomNenue Rental Other Professional Services Other tal $ b_Who was served by the grant last year9 i. Number of individuals total: ii. Number of Cupertino residents: ili.Particular community groups iv.Was the program/project/event available to the entire community/public or are there any eligibility criteria? v.Was there a charge or fee for the program/project/event(if applicable)? vi.What outreach methods did your organization use to promote the progran✓project/event(if applicable)? c.Was the program/project/event successful?Please Indicate how success was measured: 3. Please indicate any additional funding received last year from other sources and provide your financial statement if available: Attachments: Attach your financial statment, and any other helpful Information about your project. DCC Form g20 2018.odf Program Manager Signature Program Sponsor Data Signed 01/31/2021 Jame CaRAPHIC rint-DO NOT PROCESS I As Filed Data- DLN:93493133018399 $$�� Return of Organization Exempt From Income Tax OMB No 1545-0047 Form e./ Under section 601(c),527,or 4947(a)(1)of the Internal Revenue Code(except private foundations} 2®1 S ►Do not enter social security numbers on this form as it may be made public Deparnnenlofthe Open to Public Treawn, ►Go to wwwdrs.00v1Form990 for instructions and the latest information. Inspection hvernal Re+enut Seniee A For the 2019 calendar year,or tax year be innin 01-01-2018 and ending 12-31-2018 B Check if applicable C Name of organization D Employer identification number DISCOVERY COUNSELING CENTER - ❑Address change - ❑Name change %LARRY MCELVAIN ❑Initial return Doing business as ❑Final return/terminated ❑Amended return box if mad is not delivered to street address) Roam/suite E Telephone number ❑Application pending - - City or town,state or province,country,and ZIP or foreign postal code MORGAN HILL,CA 95037 - =r.,:.it.s 0 F Name and address of principal officer. H(a) Is this a group return for LA RY MC LVAIN ❑Yes ©No subordinates? MORGAWHIL 9 0 H(b) Are all subordinates Included? El Yes ❑NO I Tax-exempt stakes 0 sow)(3)3 ❑ 501 c( }( ) ( )( ) 4(insert no) Q 4947(a)(1)or 11.527 If"No,"attach a list (see.instructions) 3 Website:► WWW MYDISCOVERYCC COM H(c) Group exemption number► K Form of organization R Corporation ❑ Trust-❑ Association ❑ Other R L Year of formation 2001 M State of legal domicile CA Summary 1 Briefly describe the organization's mission or most significant activities PROVIDE MENTAL HEALTH SERVICES TO THE COMMUNITY AND SOUTH COUNTY SCHOOLS j U � 3 I 0 2 .check this box►❑ if the organization discontinued its operations or disposed of more than 25%of its net arse 0 . 3 Number of voting members of the governing body(Part VI,line 1a) . . . . . . 3 5 '6 4 Number of independent voting members of the governing body(Part VI,line lb) . . 4 4 v+ . a' S Total number of individuals employed in calendar year 2018(Part V,hne 2a) . . . . . . 5 76 �'— 6 Total number of volunteers(estimate if necessary) . . . . . . . . . . . 6 12 u Q 7a Total unrelated business revenue from Part VIII,column(C),line 12 . . . . . . 7a D h Net unrelated business taxable income from Form 990-T,line 34 . . . . . . . . 7b 1 0 Prior Year Current Year 8 Contributions and grants(Part Vill,line Ih) . . . . . . . . . 33,210 25,009 9 Program service revenue(Part VIII,line 2g) . . . . . . . 467,245 647,338 6 ' n 10 Investment income(Part VIII,column(A),lines 3,4,and 7d)- 0 1 a 11 other revenue(P4rt Vllt,column(A),lines 5,6d,Bc,9c, 10c,and 11e) 0 850 12 Total revenue--add lines 8 through 11(must equal Part V]II,column(A),line 12) 500,455 673,198 13 Grants qnd similar amounts paid(Part IX,column(A),lines 1-3) 0 0 14 Benefits paid to or for members(Part IX,column(A),line 4) . . . . . 0 0 1.5 Salaries,other compensation,employee benefits(Part IX,column(A),lines 5-10) 368,777 518,045 °' LGa Professional fundraising fees(Part IX,column(A),line Ile) . . . . . 0 0 cb Total fundraising expenses(Part IX,column(D),line 25)►a 17 Other expenses(Part IX,column(A),lines Ila-lid, llf-24e) . . . . 111,035 129,422 18 Total expenses Add Imes 13--17(must equal Part IX,column(A),line 25) 479,B12 647,467 19 Revenue less expenses Subtract line IS from line 12 . . . . . 20,643 25,731 y - Beginning of Current Year End of Year CC 19CC ¢m 20 Total assets(Part X,line 16) . . . . . . . . . . . 44r978 48,850 a 21 Total liabilities(Part X,line 26) . . . . . . . . . . . . . 29,584 13,710 Zri 22 Net assets or fund balances Subtract line 21 from line 20 15,394 35,140 Signature Block Under penalties of perjury,1 declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,it is true,correct,and complete Declaration of preparer(other than officer)is based on all information of which preparer has any knowledge +*. 2019-05-13 Signature'of officer Date Sign Here LARRY MCELVAIN F*CUTIVE DIRECTOR /Type or print name and title Print/Type preparer's name Preparer's signature Date PTIN Paid Check 11 if self-em to ed Preparer ,' Firm's name ► Firm's EIN► Use Only Firm's address► Phone no May the IRS discuss this return with the preparer shown above?(see instructions) . . . . . . . . . . . ❑Yes ❑No For Paperwork Reduction Act Notice,see the separate instructions. Cat No 11282Y Form 990(2DIG) paw pccomP�ishments 2pig) o ram�eruice a to anY Tine m thls part 111 Form 990 ent of pr 9 of S#stem a resPonse or n SGNOOIS O contains SOUS COutjy Check if Schedule s mission AND the organization` 'CHE COMMUH ND deAUiHEpLTH spp'vlcES CO of listed on Q Yes 1 Bnef[y ear whGch were n , pROJIDE MENT ram services during they . niflcantProg ©Yes sake any s+9 any Program prd tile organization and . ' " ho'x It conducts, . , . ' 2 990 or 990 W S Schedule O nt changes in d by expenses the prior Form these new servrces on eke$19n f' describe ram services,as measure total if"Yes, cease conductm9,°r m est grog to others,the and the organization of its three lar9a�and allocations 3 Schedule Q ents for each he amount of g 5as 1s91 servIces� es ram ser0re accom Mquir these ehan9 required to report If ,Yes, descr be r°4�m seN�ce reported 0)tRevenue pescnb or an'Z d 5C17.��crlp)�)organaat1 9r are e the 9 an for each P rams of 4 Section Sa andCrevenue,if any• mcludmg 9 ) expenses, 522,Q63 . )(Expenses 5 )(Revenue$ 4a (Code including grants of$ See Additional Data (ExPenses$ 4b (Code ) (Revenue S Including grants of S )(Expenses S ' 4e (Code. ) Revenue Form g9p(2018) hedule Q) services(Describe In Sc nts tnctudln9 9ra — Qthe Ot rprogram 521,063 ^' 4d (Expenses exp®uses 1e --� 4e pro T°�1 9ram servits Form 990(2018) Page 3 Checklist of Required Schedules Yes No 1 Is the organization described in section 501(c)(3) or 4947(a)(1)(other than a private foundation)?If"Yes,"complete Yes Schedule A . . . . . . . . . . . . . . . . . . . 1 2 .Is the organization required to complete Schedule 6,Schedule of Contributors(see instructions)7 2 Yes 3 Did the organization engage in direct or Indirect political campaign activities on behalf of or in opposition to candidates No for public office?If"Yes,"complete Schedule C, Part I . . 3 4 Section 501(c)(3)organizations. Did the organization engage in lobbying activities,or have a section 501(h)election in effect during the tax year? If"Yes,"complete Schedule C, Pert I/ . . . . . . . . 4 No 5 Is the organization a section 501(c)(4), 501(c)(5),or 501(c)(6)organization that receives membership dues, assessments,or similar amounts as defined in Revenue Procedure 98-19? If"Yes,"complete Schedule C,Part 111 . . . . . . . . . . . . . . . . 5 No 6 Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If"Yes,"complete Schedule D, Part I . . . 6 No t 7 Did the organization receive or hold a conservation easement,including easements to preserve open space, No the environment,historic land areas,or historic structures?If"Yes,"complete Schedule D, Part 11 7 8 Did the organization maintain collections of works of art, historical treasures,or other similar assets? i If"Yes,"complete Schedule D, Part l/I . . 8 No i I 9 Did the organization report an amount in.Part X, line 21 for escrow or custodial account liability, serve as a custodian for amounts not listed in Port X, or provide credit counseling,debt management,credit repair,or debt negotiation services?lf"Yes,"complete Schedule D, Part IV . . . . . . . . . . . . . 9 No 10 Did the organization,directly or through a related organization, hold assets in temporarily restricted endowments, 10 No permanent endowments, or quasi-endowments?If"Yes,"complete Schedule D, Part V 11 If the organization's answer to any of the following questions is"Yes,"then complete Schedule D, Parts VI,VII,VIII, IX, or X as applicable a Did the organization report an amount for land, buildings,and equipment in Part X, line i0? If"Yes,"complete Schedule D,Part V1 . . . . . . . . . . . . . . . 1la No b Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 167 If"Yes,"complete Schedule D, Part V11 . . 11b No c Did the organization report an amount for investments—program related in Part X, line 13 that is 5%or more of its total assets reported in PartX, line 16?If"Yes,"complete Schedule D, Part Vill 11c No d Did the organization.report an amount for other assets in Part X, line 15 that is 5% or more of Its total assets reported in Part X, line 167If"Yes,"complete Schedule D, Part IX . . . lid Yes e Did the organization report an amount for other liabilities in Part X, line 257 If"Yes,"complete Schedule D, PartX 11e No f Did the organization's separate or consolidated financial statements for the tax year include a footnote that addresses 11f No the organization's liability for uncertain tax positions under FIN 48(ASC 740)?If"Yes,"complete Schedule D, PartX 12a Did the organization obtain separate,independent audited financial statements for the tax year? If"Yes,"complete Schedule D, parts Xl and XII . . . . . . . . . . . . . . 12a No b Was the organization included in consolidated, independent audited financial statements for the tax year? 1.2b No If"Yes,"and if the organization answered"No"to line 12a, then completing Schedule D, Parts XI and XII is optional 13 Is the organization a school described in section 170(b)(1)(A)(n)?If"Yes,"complete Schedule 1= 13 No 14a Did the organization maintain an office,employees, or agents outside of the United States? . 14a No' b Did the organization have aggregate revenues or expenses of more than$10,000 from grantmaking,fundraising, business, investment,and program service activities outside the United States,or aggregate foreign investments valued at$100,000 or more?If"Yes,"complete Schedule F,Parts I and IV . . . . . . . . . 14b No 15 Did the organization report on Part IX, column(A), line 3'more than$5,000 of grants or other assistance to or for any foreign organization?If"Yes,'complete Schedule F, Parts II and IV 15 No 16 Did the organization report on Part IX, column(A), line 3, more than$5,000 of aggregate grants or other assistance to or for foreign individuals?If"Yes,"complete Schedule F, Parts III and IV . 16 No 17 Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, . 17 No column(A), lines 6 and 11e7 If"Yes,"complete Schedule G, Part[(see instructions) . . 18 Did the organization report more than$15,000 total of fundraising event gross income and contributions on Part Vlll, lines is and 8a?If"Yes,"complete Schedule G, Part 11 . . . . . . . . . . . 18 No 19 Did the organization report more than$15,000 of gross income from gaming activities on PartVlll, line 9a?If"Yes," complete Schedule G,Part It/ . . . . . 19 No 20a Did the organization operate one or more hospital facilities?If"Yes,"complete Schedule N 20a No b If"Yes"to line 20a,did the organization attach a copy of its audited financial statements to this return? 20b 21 Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic 21 No government on Part IX, column (A), line 17 If"Yes,"complete Schedule I, Parts I and II . . . . 22 Did the organization report more than$5,000 of grants or other assistance to or for domestic individuals on Part IX, 22 column(A), line 27 If`Yes,'complete Schedule I, Parts I and III . . . . No Form 990 (2018) Form 990 (2018) Page 4 Checklist of Required Schedules (continued) Yes No 23 Did the organization answer"Yes"to Part VII, Section A,line 3,4,or 5 about compensation of the organization's current and Former officers,directors,trustees, key employees, and highest compensated employees?If"Yes,"complete 23 No Schedule I . . . . . . . . . . . . . . . . . . . . 24a Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than$100,000 as of the last day of the year,that was issued after December 31, 20027If"Yes,"answer lines 24b through 24d and complete Schedule K If"No,"go to!me 25a . . . . . . . . . 24a No b Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception? . 24b c Did the organization maintain an escrow account other than a refunding escrow at any time.during the year to defease any tax-exempt bonds? . . . . . . . . . . . . . .. 24c d Did the organization act as an"on behalf of"issuer for bonds outstanding at any time during the year? 24d 25a Section 501(c)(3),501(c)(4),and 501(c)(29)organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year?If"Yes," 25a No complete Schedule L, Part I . . . . b Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization's prior Forms 990 or 990-EZ? 251; No If"Yes,"complete Schedule L, Part I. . . . .. . . . 26 Did the organization report any amount on Part X, line 5, 6,or 22 for receivables from or payables to any current or former officers,directors,trustees, key employees, highest compensated employees,or disqualified persons? 26 Yes If"Yes,"complete Schedule L, Part11 . . . . . . . 27 Did the organization provide a grant or other assistance to an officer,director,trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35%controlled entity or family member 27 No of any of these persons?If"Yes,"complete Schedule L, Part Ill . . . . . 28 Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds,conditions,and exceptions) a A current or former officer, director,trustee, or key employee?If"Yes,"complete Schedule L, Part IV . . . . . . . 28a No b A family member of a current or former officer,director,trustee, or key employee?If"Yes,"complete Schedule L, Part IV . . . . . . . . . . . . . . . 28b No c An entity of which a current or former officer,director,trustee,or key employee(or a family member thereof) was an officer,director,trustee,or direct or indirect owner?If"Yes,"complete Schedule L, Part IV 28c No 29 Did the organization receive more than$25,000 in non-cash contributions?If"Yes,"complete Schedule M 29 No 30 Did the organization receive contributions of art, historical treasures,or other similar assets, or qualified conservation contributions?If"Yes,"complete Schedule M . . . . . . . . . . . . . 30 No 31 Did the organization liquidate,terminate,or dissolve and cease operations?If"Yes,"complete Schedule N, Part I . 31 No 32 Did the organization sell,exchange, dispose of,or transfer more than 25%of its net assets? If"Yes,"complete Schedule N, Part H . . . . . . . . . . . 32 No 33 Did the organization own 100%of an entity disregarded as separate from the organization under Regulations sections 301 7701-2 and 301 7701-37If"Yes,"complete Schedule R, Part I . . . . 33 No 34 Was the organization related to any tax-exempt or taxable entity?If"Yes,"complete Schedule R,Part Il,III,or IV,and Part V,line 1 . . . . . . . . . . . . . . . . . . . . . . . . 34 No 35a Did the organization have a controlled entity within the meaning of section 512(b)(13)7 35a No b If'Yes'to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity 35b within the meaning of section 512(b)(13)7 If"Yes,"complete Schedule R, Part V, line 2 . . . 36 Section 501(c)(3)organizations. Did the organization make any transfers to an exempt non-charitable related organization?If"Yes,"complete Schedule R, Part V, line 2 . . . . . . . . . . . . 36 No 37 Did the organization conduct more than 5%of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes?If"Yes,"complete Schedule R, Part VI 37 No 38 Did the organization complete Schedule 0 and provide explanations.in Schedule O for Part VI, lines 11b and 191 Note. All Form 990 filers are required to complete Schedule O 38 Yes EMS Statements Regarding Other IRS Filings and Tax Compliance Check if Schedule 0 contains a response or note to any line in this Part V ❑ Yes No la Enter the number reported in Box 3 of Form 1096 Enter-0-if not applicable is 5 b Enter the number of Forms W-2G included in line is Enter-0-if not applicable lb 0 c Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling)winnings to prize winners? . . - . is Yes Form 990 (2018) Form 990 (2018) Page 5 2a Enter the number of employees reported on Form W-3,Transmittal of Wage and Tax Statements, filed for the calendar year ending with or within the year covered by this return . . . . . . . . . . . . . . . 2a 76 b If at least one is reported on line 2a,did the organization file all required federal employment tax returns? 2b Yes Note.If the sum of lines 1a and 2a is greater than 250, you may be required to a-file(see instructions) 3a Did the organization have unrelated business gross income of$1,000 or more during the year? 3a No b If"Yes,"has it filed a Form 990-T for this year?If"No"to line 3b,provide an explanation in Schedule 0 . . 3b 4a At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a 4a No financial account in a foreign country(such as a bank account, securities account,or other financial account)? b If"Yes," enter the name of the foreign country ll See instructions for filing requirements for FrnCEN Form 114, Report of Foreign Bank and Financial Accounts(FBAR) 5a Was the organization a party.to a prohibited tax shelter transaction at any time during the tax year? 5a No b 'Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction? 5b No c If"Yes,"to line Sa or 5b,did the organization file Form 8886-T? . . . . . . . 5c Ga Does the organization have annual gross receipts that are normally greater than$100,000, and did the organization 6a No solicit any contributions that were not tax deductible as charitable contributions? b If"Yes,"did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? . . 6b 7 Organizations that may receive deductible contributions under section 170(c). a Did the organization receive a payment in excess of$75 made partly as a contribution and partly for goods and services 7a -No provided to the payor? . . . . . . . . . . . . . I b If"Yes,"did the organization notify the donor of the value of the goods or services provided? . . 7b c Did the organization sell,exchange, or otherwise dispose of tangible personal property for which it was required to file Form 82827 . . . . . . . . . . . 7c No d If"Yes," indicate the number of Forms 8282 filed during the year . . . 7d 0 e Did the organization receive any funds,directly or indirectly,to pay premiums on a personal benefit contract? 7e No If Did the organization, during the year, pay premiums,directly or indirectly, on a personal benefit contract? 7f No g If the organization received a contribution of qualified intellectual property,did the organization file Form 8899 as required? . . . . . . . . _ . . 79 No h If the organization received a contribution of cars, boats,airplanes, or other vehicles, did the organization file a Form 1o98-c? . . . . . . . . . . . . . . . . . . . . . . . . 7h No 8 Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year? . . . . . . . . 8 1 9a Did the sponsoring organization make any taxable distributions under section 49667 . 9a b Did the sponsoring organization make a distribution to a donor,donor advisor,or related person? 9b 10 Section 501(c)(7)organizations. Enter a Initiation fees and capital contributions included on Part VIII, line 12 . . 10a b Gross receipts, included on Form 990, Part VIII, line 12,for public use of club facilities lob 11 Section 501(c)(12)organizations. Enter a Gross income from members or shareholders . . . . . . . b Gross income from other sources(Do not net amounts due or paid to other sources against amounts due or received from them ) . . . . . . . . . . lib 12a Section 4947(a)(1)non-exempt charitable trusts.Is the organization filing Form 990 in lieu of Form 10417 12a b If"Yes,"enter the amount of tax-exempt interest received or accrued during the year 126 13 Section 501(c)(29) qualified nonprofit health insurance issuers. a Is the organization licensed to issue qualified health plans in more than one state? Note.See the instructions for additional information the organization must report on Schedule 0 13a b Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans . 13b 0 c Enter the amount of reserves on hand . . . . . . . . . . . 13c 0 14a Did the organization receive any payments for indoor tanning services during the tax year? . . 14a No b If"Yes," has it filed a Form 720 to report these payments?If"No,'provide an explanation in Schedule 0 . 14b 15 Is the organization subject to the section 4960 tax on payment(s)of more than$1;000,000 in remuneration or excess parachute payment(s) during the year?If"Yes,"see instructions and file Form 4720, Schedule N. 15 16 Is the organization an educational institution subject to the section 4968 excise tax on net investment income? If"Yes,"complete Form 4720, Schedule 0. 16 _ Form 990 (2018) Form 990(2018) Page 6 Governance, Management,and Disclosure For each "Yes"response to lines 2 through 7b below, and for a "No"response to Imes Ba, 8b, or 10b below, describe the circumstances,processes, or changes in Schedule O See instructions Check if Schedule 0 contains a response or note to any line in this Part VI . Section A.Governing Body and Management Yes No is Enter the number of voting members of the governing body at the end of the tax year la S If there are material differences in voting rights among members of the governing body,or if the governing body delegated broad authority to-an executive committee or similar committee,explain in Schedule 0 b Enter the number of voting members included in line la, above, who are independent lb 4 2 Did any officer,director,trustee, or key employee have a family relationship or a business relationship with any other officer,director, trustee,or key employee? . . . 2 No 3 Did the organization delegate control over management duties customarily performed by or under the direct supervision 3 No of officers,directors or trustees, or key employees to a management company or other person? . 4 Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? 4 No I 5 Did the organization become aware during the year of a significant diversion of the organization's assets? 5 No 6 Did the organization have members or stockholders? . . . . . . .. 6 No i 7a Did the organization have members,stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? . . . . . . . . . . . . . . . . . . 7a No i b Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders,or 7b No I persons other than the governing body? . . . . 8 Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following a The.governing body? . . . . . . . . . Ba Yes b Each committee with authority to act on behalf of the governing body? . Bb Yes 9. Is there any officer, director,trustee,or key employee listed in Part VII,Section A, who cannot be reached at the organization's mailing address?If"Yes,"provide the names and addresses in Schedule D . . . . 9 No Section B. Policies This Section a requests information about policies not required by the Internal Revenue Code. Yes No 10a Did the organization have local chapters, branches, or affiliates? . .. . . 108 No I b If"Yes," did the organization have written policies and procedures governing the activities of such chapters,affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? lob i 11a Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? . . . . . . . iia Yes b Describe in Schedule 0 the process,if any, used by the organization to review this Form 990 12a Did the organization have a written conflict of interest policy?If"No,"go to line 13 . . . . . . 12a No b Were officers,directors,or trustees,and key employees required to disclose annually interests that could give rise to Conflicts? . . . . . . . 12b- c Did the organization regularly and coriststently monitor and enforce compliance with the policy?If"Yes,"describe in Schedule O how-this was done . . . . . 12c 13 Did the organization have a written whistleblower policy? . . 13 No 14 Did the organization have a written document retention and destruction policy? . . . 14 Yes 15. Did the process for determining compensation of the following persons include a review and approval by independent persons,comparability data,and contemporaneous substantiation of the deliberation and decision? a The organization's CEO, Executive Director, or top management official . . . 15a No b Other officers or key employees of the organization . . . . . . . . . . . . . 15b No If"Yes"to line 15a or 15b, describe the process in Schedule 0(see instructions) 16a Did the organization invest in,contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? . . . . . . . . . . . . . . . . . . . . 16a No b If"Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law,and take steps to safeguard the organization's exempt status with respect to such arrangements? . . . . . . . . . . . . 16b Section C. Disclosure 17 List the States with which a copy of this Form 990 is required to be filed► CA 18 Section 6104 requires an organization to make its Form 1023 (or 1024-A if applicable), 990,and 990-T(501(c)(3)s only)available for public inspection Indicate how you made these available Check all that apply ❑ Own website ❑ Another's website 0 Upon request ❑ Other(explain in Schedule 0) 19 Describe in Schedule 0 whether(and if so,how)the organization made its governing documents,conflict of interest policy, and financial statements available to the public during the tax year 20 State the name, address,and tele er of the person who possesses the organization's books and records ®LARRY MCELVAIN MORGAN HILL,CA 95037(408)778-5120 Form 990(2018) Form 990 (Z018) Page 7 Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors Check if Schedule 0 contains a response or note to any line in this Part V11 ❑ Section A. Officers, Directors,Trustees, Key Employees, and Highest Compensated Employees la Complete this table for all persons required to be listed Report compensation for the calendar year ending with or within the organization's tax year a List all of the organization's current officers,directors,trustees(whether individuals or organizations),regardless of amount of compensation Enter-0-in columns(D), (E), and(F) if nc compensation was paid o List all of the organization's current key employees,if any See instructions for definition of,°key employee " o List the organization's five current highest compensated employees(other than an officer, director,trustee or key employee) who received reportable compensation(Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the organization"and any related organizations e List all of the organization's former officers, key employees,or highest compensated employees who received more than$100,000 of reportable compensation from the organization and any related organizations ® List all of the organization's former.directors or trustees that received, in the capacity as a former director or trustee of the organization, more than $10,000 of reportable compensation from the organization and any related organizations List persons in the following order individual trustees or directors, institutional trustees, officers, key employees, highest compensated employees, and former such persons ❑ Check this box if neither the organization nor any related organization compensated any current officer,director,or trustee (A) (B) (C) (p) (E) (F) Name and Title Average Position (do not check more Reportable Reportable Estimated hours per than one box,unless person compensation compensation amount of other week(list is both an officer and a from the from related compensation any hours director/trustee) organization organizations from the for related X V T m (W-2/1099- (W- Z/1099- organization and organizations ,�1 ;n 2 o_, MISC) MISC) related below dotted `—�` m organizations Ime) - " � a a 0 J -i N 4 C i, I3 L (1)RANDALLRAMIREZ 12 00 ........................................ x X 9,754 0 0 .........................:. . CLINICAL DIRECTOR 0 00 (2)LARRY MCELVAIN 40 00 ............... x X 24,945 0.. R EXECUTIVE DIRECTOR 000 (3)MARC RAUSER 200 ................. x a 0 0 000 PRESIDENT (4)CLAUDIA ROSSI 200 ................ x 0 0 0 DIRECTOR 0 00 (5)PAT VICKROY 200 ....................................... ................. x 00 00 0 0 DIRECTOR Form 990 (2018) Form 990(2018)- Page 8 Section A. Officers, Directors,Trustees, Key Employees,and Highest Compensated Employees (continued) (A) (B) (C) (D) (E) M Name and Title Average. Position (do not check more Reportable Reportable Estimated hours per than one box, unless person compensation compensation amount of other ' week (list is both an officer and a from the from related compensation any hours director/trustee) organization(W- organizations(W- from the for related 1 y T 2/1099-MISC) 2/1099-MISC) organization and organizations w ;n �,� related below dotted " r 7 organizations line) ti Ej 7 2 b . `-' ip Z T Ii T T. L I I I 1,b Sub-Total . . . . . . . . . . . . . . . . ► c Total from continuation sheets to Part VI I,Section A . . . ► d Total(add lines 11b and 1c) ► 34,699 01 o 2 Total number of individuals(including but not limited to those listed above)who received more than$100,000 of reportable compensation from the organization► 0 _ I Yes No ! 3 Did the organization list any former officer,director or trustee, key employee, or highest compensated employee on line ia7 If"Yes,"complete Schedule J forsuch individual 3 No 4 For any individual listed on line ia, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,0007 If"Yes,"complete Schedule J for such individual . . f 4 No ; 5 Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for l services rendered to the organization7If"Yes,"complete Schedule J for such person . . . . . • g No Section B. Independent Contractors 1 Complete this table for your five highest compensated independent contractors that received more than$100,000 of compensation from the organization Report compensation for the calendar year ending with or within the organization's tax year (A) (B) (C) Name and business address Description of services Compensation 2 Total number of independent contractors(including but not limited to those listed-above)who received more than $100,000 of compensation from the organization P Form 990(2018) Form 990(2018) Page 9 •4' Statement of Revenue Check if Schedule D contains a response or note to any line in this Port VIII ❑ (A) (B) (C) (0) Total revenue Related or Unrelated Revenue exempt business excluded from function revenue tax under sections revenue 512-514 la Federated campaigns La 0 eb Membership dues lb 1 0 (j E c Fundraising events lc I 0 iQ d Related organizations ld I 0 L7 . a Government grants(contributions) 1e 0 C f All other contributions,gifts,grants, ' o and similar amounts not included if 25,009 07 above , 9 Noncash contributions included a e in lines la-If$ 0 � . tCD r- h Total,Add lines la-If . . . . . . . p 25,Q09 y Business Code 2a Counseling and Community services 621420 647,330 647,338 0 Q y b c d , � e R 0o f All other program service revenue 647,338 gTotal.Add lines 2a-2f'. ► 3 Investment income(Including dividends,Interest,and other 1 t 0 0 similar amounts) . . . . . . . ► 4 Income from investment of tax-exempt bond proceeds 111. 0 0 Q o 1 5 Royalties . ► Q o Q Q (i)Real (u)Personal 6a Gross rents 850 0 b Less rental expenses 0 0 - - c Rental income or 850 0 _ - (toss) d Net rental Income or(loss) - 850 e50 Q - Qli (i)Securities (it)other 7a Gross amount from sales of - assets other than iaventmry b Less costar _ other basis and sales expenses - c Gam or(lass) - d Net gain or(loss) - Ba Gross income from fundraising events d (not including$ b of contributions reported on line 1c) See Part IV,line 18 . . . a 0 cc bLess dlrectexpenses b 0 c Net income or(loss)from fundraising events f 0 0 Q .'�.. 9a Gross income from gaming activities ' O See Part IV,line 19 a a bLess chrectexpenses . b 0 a Net income or(loss)from gaming activities ► 0 0 o Q lOaGross sales of inventory,less returns and allowances a b Less cost of goods said b c Net income or(loss)From sales of inventory ► Miscellaneous Revenue Business Code 11a b c dAll other revenue . . . . @Total.Add lines Ila-lid . ► Q 12 Total revenue.See Instructions p, - - 673,198 648,189 4)1 0 Form 990(2018) Form 990(2018) Page 10 Statement of Functional Expenses Section 5O1(c)(3) and 5O1(c)(4) organizations must complete all columns All other organizations must complete column(A) Check if Schedule 0 contains a response or note to any line in this Part IX . ❑ Do not include amounts reported on.lines 6b, (A) Program Management and {D} 7b,8b,9b,and 10b of Part VIII. Total expenses Fundraisingexpenses expenses general expenses 1 Grants and other assistance to domestic organizations and domestic governments See Part IV, line 21 2 Grants and other assistance to domestic individuals See Part IV, line 22 3 Grants and other assistance to foreign organizations, foreign governments, and foreign individuals See Part IV, line 15 and 16 4 Benefits paid to or for members 5 Compensation of current officers,directors,trustees,and 34,699 34,699 0 D key employees . . 6 Compensation not included above,to disqualified persons(as 0 0 0 D defined under section 4958(f)(1))and persons described in section 4958(c)(3)(B) 7 Other salaries and wages 441,893 381,214 60,679 D 8 Pension plan accruals and contributions(include section 401 0 0 0 0 (k)and 4O3(b) employer contributions) . 9 Other employee benefits . . . D 0 0 0 10 Payroll taxes . , 41,453 36,291 5,162 0 11 Fees for services(non-employees) a Management . . . . . . 0 0 D 0 b Legal . 0 0 0 D c Accounting . . . . 1,844 922 922 0 d Lobbying . . 0 0 0 0 e Professional fundraising services See Part IV, line 17 0 0 f Investment management fees . . . . . . 0 0 0 0 g Other(If line 11g amount exceeds 10%of line 25,column 8,445 5,373 3,072 D (A) amount, list line iig expenses on Schedule O) 12 Advertising and promotion . 2,571 1,286 1,285 0 13 -Office expenses . . . 9,605 4,803 4,.802 D 14 Information technology . . 5,506 2,753 2,753 0 15 Royalties 0 0 0 D 16 Occupancy 58,126 29,063 29,063 0 17 Travel . . . . . . . . . . 0 0 0 D 18 Payments of travel or entertainment expenses for any 0 0 0 0 federal,state, or local public officials 19 Conferences, conventions, and meetings 0 0 0 0 20 Interest . 757 379 378 0 21 Payments to affiliates . . . . . . . 0 0 0 0 22 Depreciation, depletion,and amortization 0 D 0 0 23 Insurance . 10,404 5,202 5,202 0 24 Other expenses Itemize expenses not covered above(List miscellaneous expenses in line 24e If line 24e amount exceeds 10%of line 25,column (A)amount, list line 24e expenses on Schedule 0 ) a Telecommunications 6,927 3,464 3,463 0 b Bank charges 6,237 3,119 3,118 0 c Community program events,training, and materials 5,987 5,987 0 0 d Utilities 5,213 2,607 2,606 0 e All other expenses 7,800 3,901 3,899 0 25 Total functional expenses.Add lines 1 through 24e 647,467 521,063 126,404 0 26 Joint costs. Complete this line only if the organization reported in column (B)joint costs from a combined educational campaign and fundraising solicitation Check here lb ❑ if following SOP 98-2(ASC 958-720) Form 990 (2018) Form 990 (2018) Page 11 Balance Sheet Check if Schedule 0 contains a response or note to any line in this Part IX ❑ (A) (8) Beginning of year End of year 1 Cash-rlon-interest-bearing . . 313177 1 36,004 2 Savings and temporary cash investments . 0 2 6,568 3 Pledges and grants receivable, net . . . 0 3 0 4 Accounts receivable, net . 0 4 0 5 Loans and other receivables from current and former officers, directors, trustees, key employees,and highest compensated employees Complete 0 5 0 Part 11 of Schedule L . 6 Loans and other receivables from other disqualified persons(as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(6),and contributing employers and sponsoring organizations of section 501(c)(9) 0 6 0 voluntary employees' beneficiary organizations (see instructions)Complete J v, Part II of Schedule L .. . . . . . . . . . . . I 7 Notes and loans receivable, net . . . . 0 7" 0 h 8 Inventories for sale or use . . 0 8 0 Q 9 Prepaid expenses and deferred charges . 3,940 9 1,835 L0a Land,buildings,and equipment cost or other basis Complete Part VI of Schedule D Loa D b Less accumulated depreciation 10b 0 0 10c 0 11 Investments—publicly traded securities 0 11 0 12 Investments—other securities See Part IV, line 11 . 0 12 0 13 Investments—program-related See Part IV,line 11 0 13 0 14 Intangible assets . . 0 14 0 15 Other assets See Part IV, line 11 . 4,861 15 4,443 16 Total assets.Add lines 1 through 15 (must equal line 34) 44,978 16 48,850 17 Accounts payable and accrued expenses 0 17 0 18 Grants payable 0 18 0 19 Deferred revenue . . . 0 19 0 20 Tax-exempt bond liabilities . . . . . . . . 0 20 0 V% 21 Escrow or custodial account liability Complete Part IV of Schedule D 0 21 0 22 Loans and other payables to current and former officers,directors, trustees, key employees,highest compensated employees,and disqualified M persons Complete Part II of Schedule L 11,400 22 10,093 ' --I 23 Secured mortgages and notes payable to unrelated third parties 17,631 23 1,120 24 Unsecured notes and loans payable to unrelated third parties 553 24 2,497 25 Other liabilities(including federal income tax, payables to related third parties, 0 25 0 F and other liabilities not included on lines 17-24). I Complete Part X of Schedule D E 26 Total Iiabilities.Add lines 17 through 25 . 29,584 26 13,710 l Organizations that follow SEAS 117 (ASC 958),check here® ❑ and tr complete lines 27 through 29,and lines 33 and 34. I r 27 Unrestricted net assets 27 28 Temporarily restricted net assets . 28 'a 29 Permanently restricted net assets 29 W Organizations that do not follow SFAS 117 (ASC 958), check here► 0 and complete lines 30 through 34. 0 30 Capital stock or trust principal,or current funds . . . 0 30 0 31 Paid-in or capital surplus,or land, budding or equipment fund 0 31 0 'A a 32 Retained earnings,'endowment, accumulated income,or other funds 15,394 32 35,140 D 33 Total net assets or fund balances . . . . . . . . , . 15,394 33 35,140 Z 34 Total liabilities and net assets/fund balances . 44,978 34 48,850 Form 990 (2018) Form 990(2018) Page 12 Reconcilliation of Net Assets Check if Schedule O contains a response or note to any line in this Part XI ❑ 1 Total revenue(must equal Part VIII;column (A), Ime 12) . . . 1 673,198 2 Total expenses(must equal Part IX,column (A), line 25) . . . . . . . . . . . . 2 647,467 3 Revenue less expenses Subtract line 2 from line 1 . 3 25,731 4 Net assets or fund balances.at beginning of year(must equal Part X, line 33,column (A)) 4 15,394 5 Net unrealized gains(losses)on investments . . . . . S 0 . 6 Donated services and use of facilities . . . .. 6 0 7 Investment expenses . . . . . 7 0 8 Prior period ad]ustments . . 8 -5,913S 9 Other changes in net assets cr fund balances(explain in Schedule O) . 9 0 10 Net assets or fund balances at end of year Combine lines 3 through 9(must equal Part X, line 33,,column (B)) 10 35,140 Financial Statements and Reporting Check if Schedule O contains a response or note to any line in this Part XII . ❑ Yes No 1 Accounting method used to prepare the Form 990 0 Cash ❑ Accrual ❑Other IF the organization changed its method of accounting from a prior year or checked "Other,"explain in Schedule O 2a Were the organization's Financial statements compiled or reviewed by an independent accountant? 2a No IF'Yes,'check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both ❑ Separate basis ❑ Consolidated basis ❑ Both corsolidated and separate basis b Were the organization's financial statements audited by an independent accountant? 2b No If'Yes,'check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis,or both ❑ Separate basis ❑ Consolidated basis ❑ Both consolidated and separate basis c If"Yes,"to line 2a or 2b, does the orgamzaticn have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? 2c If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O 3a As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-1337 3a No b If"Yes,"did the organization undergo the required audit or audits?If the organization did not undergo the required audit or audits, explain why in Schedule O and-describe any steps taken to undergo such audits 3b Form 990f2018) OOOP C!- t� Sa VersF � i O Sa'� N Vie. d�SCO �co UN�tQMMUN� N� 90 4�p18� Sit LEnea OZHE5° 5A parm`� 90,park 1 cp%ps P1 5 FaR 4ZNG V, efile GRAPHIC prilnt- DO NOT PROCESS As Filed Data - DLN: OMB No 1545-0047 SCHEDULE A Public Charity Status and Public Support (Form 990 or Complete if the organization is a section 501(c)(3)organization or a section ®� 990EZ) 4947(a)(1) nonexempt charitable trust. ►Attach to Form 990 or Form 990-EZ. ► www.irs.gov/Form990 information.Go to ww.irsov/Form990 for the latest infoti Deparuneul of the TmMln Open Inspection Name.of the organization Employer identification number DISCOVERY COUNSELING CENTER NOWFIF—Reason for Public Charity Status All organizations must complete this art. See instructions. The organization is not a private foundation because it is (For lines 1 through 12,check only one box) { 1 ❑ A church,convention of churches,or association of churches described in section 170(b)(1)(A)(i). 2 ❑ A school described in section 170(b)(1)(A)(1i). (Attach Schedule E (Form 990 or 990-EZ) ) 3 A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii). 4 A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's ' name,city, and state 5 An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170 (b)(1)(A)(iv).(Complete Part II) I 6 F1 A federal,state,or local government or governmental unit described in section 170(b)(1)(A)(v). 7 An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II } 8 0 A community trust described in section 170(b)(1)(A)(vi) (Complete Part II ) 9 0 An agricultural research organization described in 170(b)(1)(A)(ix)operated in conjunction with a land-grant college or university or a non-land grant college of agriculture See instructions Enter the name, city, and state of the college or university 10 Q An organization that normally receives (1) more than 331/30/a of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions—subject to certain exceptions, and (2)no more than 331/3%of its support from gross investment income and unrelated business taxable income(less section 511 tax)from businesses acquired by the organization after 3une 30, 1975 See section 509(a)(2). (Complete Part III) 11 El An organization organized and operated exclusively to test for public safety See section 509(a)(4). 12 An,organization organized and operated exclusively foi•the benefit of,to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1)or section 509(a)(2).See section 509(a)(3).Check the box in lines 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f,and 12g a Type I.A supporting organization operated, supervised, or controlled by its supported organization(s),typically by giving the supported organization(s)the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization You must complete Part IV,Sections A and B. b Type II.A supporting organization supervised or controlled in connection-with its supported organization(s), by having control or management of the supporting organization vested-in the same persons that control or manage the supported organization(s) You must complete Part IV,Sections A and C. c n Type III functionally integrated.A supporting organization operated in connection with,and functionally integrated with, its supported organization(s) (see instructions) You must complete Part IV,Sections A, D,and E. d n Type III non-functionally integrated.A supporting organization operated in connection with its supported organization(s)that is not p functionally integrated The organization generally must satisfy a distribution requirement and an attentiveness requirement(see instructions) You must complete Part IV,Sections A and D, and Part V. e ❑ Check this box if the organization received a written determination from the IRS that it is a Type I,Type II,Type III functionally integrated,or Type III non-functionally Integrated supporting organization f Enter the number of supported organizations J Provide the following information about the supported organization(s) (i) Name of supported (0)EIN (01)Type of (iv) Is the organization listed (v)Amount of (vi)Amount of organization organization in your governing document? monetary support other support(see (described on lines (see instructions) instructions) i- io above(see instructions)) Yes No Total EHE For Paperwork Reduction Act Notice,see the Instructions for Schedule A(Form 990 or 990-EZ) 2018 Form 990 or 990-EZ. Schedule A(Form 990 or 990-EZ)2018 Page 2 Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv), 170(b)(1)(A)(vi),and 170 — (b)(1)(A)(ix) (Complete only if you checked the box on line 5, 7, 8, or 9 of Part I or if the organization faded to qualify under Part III. If the organization fails to qualify under the tests listed below, lease complete Part Ili.) Section A. Public Support Calendar year (a) 2014 (b) 2015 (c) 2016 d a (or fiscal year beginning in)� { ) 2017 ( )2018 (f)Total 1 Gifts, grants,contributions, and membership fees received (Do not include any"unusual grant") 2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf 3 The value of services or facilities furnished by a governmental unit to the organization without charge 4 'Total.Add Imes 1 through 3 5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2%of the amount shown on line 11,column(f) 6 Public support. Subtract line 5 From line 4 Section B. Total Support ! Calendar year (or fiscal year beginning in)► (a)2014 (b)2015 (c)2016 (d)2017 (e)2018 (f)Total 7 Amounts from line 4 8 Gross income from interest, dividends, payments received on securities loans, rents,royalties and income from similar sources 9 Net income from unrelated business activities,whether or not the business is regularly carried on 10 Other income Do not include gam or loss From the sale of capital assets (Explain in Part VI ) ! 11 Total support.Add lines 7 through 10 I 12 Gross receipts from related activities,etc (see instructions) 12 13 First five years. If the Form 990 is for the organization's first,second,third, fourth,or fifth tax year as ii section 501(c)(3)organization, I check this box and.stop here . . , . . . . . . . . . ❑ Section C. Computation of Public Support Percentage 14 Public support percentage for 2018(line 6, column (f)divided by line 11, column(f)) 14 15 Public support percentage for.2017 Schedule A, Part II, line 14 15 16a 33 1/30/0 support test-2018.If the organization.did not check the box on line 13, and line 14 is 33 1/3%or more,check this box l and stop here.The organization qualifies as a publicly supported organization ► ❑ b 33 113%support test--2017.If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3"/d or mare, check this box and stop here.The organization qualifies as a publicly supported organization ► ❑ 17a 100/o-facts-and-circumstances test-2018.If the organization did not check a box.on line 13, 16a,or 16b,and line 14 i is 10%or more, and if the organization meets the"facts-and-circumstances"test,check this box and stop here. Explain in Part VI how the organization meets the"facts-and-circumstances"test The organization qualifies as a publicly supported organization ► ❑- b 10%-facts-and-circumstances test--2017.If the organization did not check a box on line 13, 16a, 16b, or 17a,and line 15 is 10% or more,and if the organization meets the "Facts-and-circumstances"test,check this box and stop here. Explain in Part VI how the organization meets the"facts-and-circumstances"test. The organization qualifies as a publicly supported organization ► ❑ 18 Private foundation.If the organization did not check a box on line 13, 16a,16b, 17a,or 17b,check this box and see instructions ► ❑ Schedule A(Form 990 or 990-lEZ)2018 Schedule A(Form 990 or 990-EZ) 2018 Page 3 Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.) Section A. Public Support - -Calendar year (a) 2014 (b) 2015 (c) 2016 (d)2017 (e)2018 (f)Total (or fiscal year beginning in)0- 1 Gifts,grants, contributions, and membership fees received (Do not 15,939 18,173 27,973 33,210 25,009 120,304 include any"unusual grants") 2 Gross receipts from admissions, merchandise sold or services performed,or facilities furnished in 149,810 229,417 365,472 467,245 673,198 1,885,142 any activity that is related to the organization's tax-exempt purpose 3 Gross receipts from activities that are not an unrelated trade or business under section 513 4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf 3 The value of services or facilities furnished by a governmental unit to the organization without charge 6 Total.Add lines 1 through 5 165,749 247,590 393,445 500,455 698,207 2,005,446 7a'Amounts included on lines 1,2, and 3 received from disqualified persons b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1%of the amount on line 13 for the year c Add lines 7a and 7b e Public support.(Subtract line 7c from line 6 2,005,446 Section B. Total Support Calendar year(or fiscal year beginning in)1► (a) 2014 (b)2015 (c) 2016 (d) 2017 (a) 2018 (f)Total 9 Amounts from line 6 165,749 24.7,590 393,445 S00,455 698,207 2,005,446 10a Gross income from interest, dividends,payments received on D 0 0 0 1 1 securities loans, rents,royalties and income from similar sources b Unrelated business taxable income (less section 511 taxes)from businesses acquired after June 30, 1975 c Add lines 10a and 10b 0 0 0 0 1 1 11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on 12 Other income Do not include gain or loss from the sale of capital assets(Explain in Part VI ) 13 Total support. (Add lines 9, 10c, 165,749 247,590 393,445 500,455 698,208 2,005,447 11,and 12 ) 14 First five years.If the Form 990 is for the organization's first, second, third,fourth,or fifth tax year as a section 501(c)(3)organization, check this box and stop here ❑ Section C.Coin uti�ation of Public Support Percents e 1s Public support percentage for 2018(line 8,column(f)divided by line 13,column (f)) is 100 000 16 Public support percentage from 2017 Schedule A, Part III, line 15 kL6 100 0/0 Section D. Computation of Investment Income Percentage 17 Investment income percentage for 2018 (line 10c, column (f) divided by line 13,column (f)) 17 0 18 Investment income percentage from 2017 Schedule A, Part III, line 17 18 0 19a 331/3%support tests-2018.If the organization did not check the box on line 14,and line 15 is more than 33 1/3111o;and line 17 is not more than 33 1/3%, check this box and stop here.The organization qualifies as a publicly supported organization If 0 b 33 1/3%support tests--2017. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3%and line 18 is not more than 33 1/3%,check this box and stop here.The organization qualifies as a publicly supported organization F ❑ 20 Private foundation.If the organization did not check a box on line 14, 19a,or 19b,check this box and see instructions ► ❑ Schedule A fForm 990 or 990-EZI 2018 Schedule A(Form 990 or 990-EZ) 2018 Page 4 Supporting Organizations (Complete only if you checked a box on line 12 of Part I If you checked 12a of Part I,complete Sections A and B If you checked 121b of Part I,complete Sections A and C If you checked 12c of Part I, complete Sections A,D, and E If you checked 12d of Part I,complete Sections A and D, and complete Part V) _ Section A. All Supporting Organizations Yes No 1 Are all of the organization's supported organizations listed by name in the organization's governing documents) If"No,"describe in Part VI how the supported organizations are designated If designated by class or purpose, describe the designation If historic and continuing relationship, explain 1 2 Did the organization have any supported organization that does not have an IRS determination of status under section 509 (a)(1)or(2)?If"Yes,"explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1)or(2) 2 3a Did the organization have a supported organization described in section 501(c)(4), (5),or(6)?If"Yes,"answer(b)and(c) below 3a b Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or(6)and satisfied the public support tests under section 509(a)(2)?If"Yes,"describe on Part Vl.when and how the organization made the determination 3b c Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If"Yes,"explain in Part VI what controls the organization put in place to ensure such use 3c 4a Was any supported organization not organized in the United States ("foreign supported organization")7If"Yes"and of you checked 12a or 12b in Part I,answer(b)and(c)below 4a b Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization?If"Yes,"describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations 4b c Did the organization support any foreign supported organization that does not have an IRS.determination under sections 501(c)(3)and 509(a)(1)or(2)7If"Yes,"explain in PartVr what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B)purposes 4c Sa Did the organization add,substitute, or remove any supported organizations during the tax year?If"Yes,"answer(b)and (c)below(of applicable) Also,provide detail in Part VI,including(i)the names and FIN numbers of the supported organizations added, substituted, or removed, (or)the reasons for each such action, (m)the authority under the organization's organizing document authorizing such action, and(iv)how the action was accomplished(such as by Sa amendment to the organizing document) b Type I or Type II only.Was any added or substituted supported organization part of a class already designated in the organization's organizing document? 5b c Substitutions only.Was the substitution the result of an event beyond the organization's control? 5c 6 Did the organization provide support(whether in the form of grants or the provision of services or facilities)to anyone other than(i)its supported organizations, (u) individuals that are part of the charitable class benefited by one or more of its supported organizations,or(in)other supporting organizations that also support or Lbenefit one or more of the filing organization's supported organizations?If"Yes,"provide detail in Part VI. 6 7 Did the organization provide a grant, loan, compensation,or other similar payment to a substantial contributor(defined in section 4958(c)(3)(C))r a family member of a substantial contributor, or a 35%controlled entity with regard to a substantial contributor?If"Yes,"complete Part I of Schedule L(Form 990 or 990-FZ) 7 8 Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 79 If"Yes," complete Part I of Schedule L(Form 990 or 990-FZ) $ 9a Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946(other than foundation managers and organizations described in section 509(a)(1)or(2))?If"Yes," provide detail in Part VI. 9a b Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest?If"Yes,'provide detail+n Part VI. 9b c Did a disqualified person(as defined in line 9a)have an ownership interest in,or derive any personal benefit from,assets in which the supporting organization also had an interest?If"Yes,"provide detail in Part VI. 9c IL Da Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations,and all Type III non-functionally integrated supporting organizations)?If"Yes," answer line 10b below 10a b Did the organization have any excess business holdings in the tax year?(Use Schedule C, Form 4720, to determine whether the organization had excess business holdings) lOb Schedule A(Form 990 or 990-EZ) 2018 Schedule A (Form 990 or 990-EZ) 2018 _ Page 5 ;Supporting Organizations (continued) yi�s No 11 Has the organization accepted a gift or contribution from any of the following persons? a A person who directly or-indirectly controls, either alone or together with persons described in(b)and (c)below,the governing body of a supported organization? Ila b A family member of a person described in (a) above? lib c A 350/o controlled entity of a person described in (a)or(b)above?If"Yes"to a, b, or c, provide detail in Part VI llc Section B. Type I Supporting Organizations Yes No 1 Did the directors,trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the'organization's directors or trustees at all times during the tax year?If"No,"describe in Part VI how the supported organization(s)effectively operated,supervised, or controlled the organization's activities If the organization had more than one supported organization,describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organ izatrons and what conditions or restrictions, if any,applied to such powers during the tax year 1 2 laid the organization operate for the benefit of any supported organization other than the supported organization(s)that operated, supervised, or controlled the supporting organization?If"Yes,"explain in Part VI how providing-such benefit carried out the purposes of the supported organization(s)that operated,supervised or controlled the supporting 2 organization Section C. Type II Supporting Organizations Yes No 1 Were a majority of the organization's directors or trustees during the tax year also a majority of the directors or trustees of each of the organization's supported organization(s)?If"No,"describe in Part VZ how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s) 1 I Section D.All Type III Supporting Organizations Yes No 1 Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization's tax year, (i)a written notice describing the type and amount of support provided during the prior tax year, (n)a copy of the Form 990 that was most recently filed as of the date of notification,and (ni) copies of the organization's governing documents in effect on the date of notification,to the extent not previously provided? 1 2 Were any of the organization's officers,directors,or trustees either(i)appointed or elected by the supported organization (s)or(u)serving on the governing body of a supported organization?If"No,"explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s) i 2 3- By reason of the relationship described in (2), did the organization's supported organizations have a significant voice in the organization's investment policies and in directing the use of the organization's income or assets at all times during the tax year?If"Yes,"describe in Part VI the rule the orgarnization's supported organizations played in this regard 3 Section,E. 1[ype.III Fu inctiona I ly-linteg rated §Rpportin Or anizations l 1 Check the box next to the method that the organization used to satisfy the Integral Part Test during the year(see instructions) a F1 The organization satisfied the Activities Test Complete line 2 below b El The organization is the parent of each of its supported organizations Complete line 3 below c n The organization supported a governmental entity Describe in Part VI how you supported a government entity(see instructions) f 2 Activities Test Answer(a)and(b) below. Yes Na a Did substantially all of the organization's-activities during the tax year directly further the exempt purposes of the supported organizations)to which the organization was responsive?If"Yes,"then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations,and how the organization determined that these activities constituted substantially all of its activities 2a b Did the activities described in (a)constitute activities that, but for the organization's involvement,one or more of the organization's supported organization(s)would have been engaged in?If"Yes,"explain in Part VI the reasons for the organization's position that its supported organization(s)would have engaged in these activities but for the organization's involvement 2b 3 Parent of Supported Organizations Answer(a)and (b) below. a Did the organization have the power to regularly appoint or elect a majority of the officers,directors,or trustees of each of 3a the supported organizations?provide details in Part VL b Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations?If"Yes,"describe in Part VI. the role played by the organization in this regard 36 Schedule A(Form 990 or 990-EZ) 2018 Schedule A(Form 990 or 990-EZ) 2018 Page 6 Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations i Check here if the organization satisfied the integral Part Test as a qualifying trust on Nov 20, 1970(explain in Part VI) See instructions.All other Type III non-functionally integrated supportina or arizations must complete Sections A through E Section A- Adjusted Net Income (A)Pnor Year (13)Current Year (optional) 1 Net short-term capital gain 1 2 Recoveries cf prior-year distributions 2 3 Other gross income(see instructions) 3 4 Add lines 1 through 3 4 5 Depreciation and depletion 5 6 Portion of operating expenses paid or incurred for production or collection of gross fi income or for management,conservation,or maintenance of property held for production of income(see instructions) 7 Other expenses(see instructions) 7 8 Adjusted Net income(subtract lines 5,6 and 7 from line 4) 8 Section B - Minimum Asset Amount (A)Prior Year (S)Current Year (optional) 1 Aggregate Fair market value of all non-exempt-use assets(see instructions for short tax year or assets held For part of year) 1 a Average monthly value of securities la b Average monthly cash balances 1b c Fair market value of other non-exempt-use assets is d Total(add lines la, 1b, and 1c) 1d e Discount claimed for blockage or other factors (explain in detail in Part VI) 2 Acquisition indebtedness applicable to non-exempt use assets 2 3 Subtract line 2 from line 1d 3 4 Gash deemed held for exempt use Enter 1-1/21/o of hne 3 (for greater.amount, see instructions) 4 5 Net value of non-exempt-use assets(subtract line 4 from line 3) 5 6 Multiply line 5 by 035 6 7 Recoveries of prior-year distributions 7 8 Minimum Asset Amount(add line 7 to line 6) 8 Section C- Distributable Amount Current Year 1 Adjusted net income for prior year(from Section A, line 8, Column A) 1 2 Enter 851/a of line 1 2 3 Minimum asset amount for prior year(from Section B, line 8, Column A) 3 4 Enter greater of line 2 or line 3 4 5 Income tax imposed in prior year 5 6 Distributable Amount. Subtract line 5 from line 4,unless subject to emergency 6 temporary reduction (see instructions) 7 Check here if the current year is the orgamzation's first as a non-functionally-Entegrated Type III supporting organization(see instructions) Schedule A(Form 990 or 990-EZ) 2018 Schedule A(Form 990 or 990-EZ)2018 Page 7 Type III Non-Functionally integrated 509(a)(3) Supporting Organizations (continued) Section D- Distributions Current Year i Amounts paid to supported organizations to accomplish exempt purposes 2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations,in excess of Income from activity 3 Administrative expenses paid to accomplish exempt purposes of supported organizations 4 Amounts paid to acquire exempt-use assets 5 Qualified set-aside amounts(prior IRS approval required) 6 Other distributions (describe in Bart VI) See instructions 7 Total annual distributions.Add Imes 1 through 6 8 Distributions to attentive supported organizations to which the organization is responsive(provide details in Part VI) See instructions 9 Distributable amount for 2018 from Section C,line 6 I i 10 Line 8 amount divided by Line 9 amount Section E - Distribution Allocations (see instructions) Excess Distributions Underdistributions Distributable Pre-2018 Amount for 2018 1 Distributable amount for 2018 from Section C, line i 6 2 Underdistributions, if any,for years prior to 201E (reasonable cause required--explain in Part VI) See instructions 3 Excess distributions carryover,if any,to 2018. a From 2013. b From 2014. c From 2015. d From 2016. _ e From 2017. f Total of lines 3a through e g Applied to underdistributions of prior years h Applied to 2018 distributable amount i Carryover from 2013 not applied (see instructions) - - 7 Remainder Subtract lines 3g, 3h,and 31 from 3f 4 Distributions for 2018 from Section D,line 7 $ a Applied to underdistributions of prior years b Applied to 2018 distributable amount c Remainders Subtract lines 4a and 4b from 4 l 5 Remaining underdistributions for years prior to 2018, if any Subtract lines 3g and 4a from line 2 If the amount is greater than zero, explain in Part VI i See instructions 6 Remaining underdistributions for 2018 Subtract lines 3h and.4b from line 1 If the amount is greater than zero,explain in Part VI See instructions 7 Excess distributions carryover to 2019.Add lines 3]and 4c 8 Breakdown of line 7 a Excess from 2014. b Excess from 2015. e Excess from 2016. d Excess from 2017. e Excess from 2018. . Schedule A(Form 990 or 990-Ex) (2018) pas s°ft Say t4se\.J�4G CE CAR Pa`t ,$ 21,�at� sO�are ve Eg3 CQ\J��Y CQU park Iii,se'tkon+c,V e 1 �dditio S;Me pLS a 1�a or 1�2 part i line 1e,Pa See ��Unes 1 an5e�an 6, rm�t�on �` paw 11,\011 set t00% e 1,Part add�k�onal nfo red ay par"park I rt , for am lanatEonsll 11b,a2d,33 a GamPlelte th 5 Pe EZ7 pr¢V`de ttr6 gal9o-, 1me51�' and 6 AlSo p or tea, at"On' 4�arkT�t,53, 5ect�n E \Jnes.2�5f ch A tporm 99 eOt I-Lofo b,3c,4 3, Sew S edu\e uppD pjeIn`on�'\g an 9n and part OU ' �o hest Partly, lines 5 OT n acts Aid 5�$uct�o ExPlanatkon Reference P,et�rc' efile GRAPHIC print- DO NOT PROCESSJ As Filed Data _ DLN: SCHEDULE D Supplemental Financial Statements OMB No 1545-0047 (Form 990) 2018 ►Complete if the organization answered"Yes,`'an Form 99D, Part IV, line 6, 7,8, 9, 10, Ila, Ilb, 11c, Ild, Ile, 11f, 12a,or 12b. Departiuent of dte Treaixin ►Attach to Form 990. Open to Public Intemnl Re%enue SeTt ice 1 ►Go to www.frs.aoy/Porm990 for the latest information. Inspection Name of the organization Employer identification number DISCOVERY COUNSELING CENTER Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Forum 990 Part IV line 6, (a) Donor advised funds (b)Funds and other accounts 1 Total number at end of year 2 Aggregate value of contributions to(during year) 3 Aggregate value of grants from (during year) 4 Aggregate value at end of year 5 Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization's property, subject to the organization's exclusive legal control? ❑ Yes ❑ No 6 Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor,or for any other purpose conferring impermissible private benefit? ❑ Yes ❑ No Conservation Easements. Complete if the organization answered "Yes" on Form 990,Part IV, line 7. 1 Purpose(s)of conservation easements held by the organization (check all that apply) ❑ Preservation of land for public use (e g , recreation or education) ❑ Preservation of an historically important land area ❑ Protection of natural habitat ❑ Preservation of a certified historic structure ❑ Preservation of open space 2 Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year Held at the End of the Year a Total number of conservation easements 2a b Total acreage restricted by conservation easements 2b c Number of conservation easements on a certified historic structure included in(a) 2c d Number of conservation easements included in (c) acquired after 7/25/06, and not on a historic 2d structure listed in the National Register 3 Number of conservation easements modified,transferred, released, extinguished,or terminated by the organization during the tax year 0- 4 Number of states where property subject to conservation easement is located 0- 5 Does the organization have a written policy regarding the periodic monitoring, inspection,handling of violations, and enforcement of the conservation easements it holds? ❑ Yes ❑ No 6 Staff and volunteer hours devoted to monitoring,inspecting,handling of violations, and enforcing conservation easements during the year ► J 7 Amount of expenses incurred in monitoring, inspecting, handling of violations,and enforcing conservation easements during the year 8 Does each conservation easement reported on line 2(d)above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? ❑ Yes ❑ No 9 In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement,and balance sheet, and include, if applicable,the text of the footnote to the organization's financial statements that describes the organization's accounting,for conservation easements Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets. Complete if the organization answered "Yes" on Form 990, Part IV, line 8. la If the organization elected; as permitted under SFAS 116(ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures,or other similar assets held for public exhibition,education, or research in furtherance of public service, provide,in Part XIII,the text of the footnote to its financial statements that describes these items b If the organization elected, as permitted under SFAS 116(ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures,or other similar assets held for public exhibition, education,or research in furtherance of public service,provide the following amounts relating to these items (1)Revenue included on Form 990, Part VIII, line 1 ► $ (ii)Assets included in Form 990, Part X ► $ 2 If the organization received or held works of art, historical treasures,or other similar assets for financial gam, provide the following amounts required to be reported under SFAS 116(ASC 958) relating to these items a Revenue included on Form 990, Part VIII, line 1 ► $ b Assets included in Form 990, Part X IN. $ For Paperwork Reduction Act,Notice,see the Instructions for Form 990. Schedule D(Form 990) 2018 Schedule D(Form 990)201B Page 2 Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued) 3 Using the organization's acquisition, accession,and other records,check any of the following that are a significant use of its collection items(check all that apply) a ❑ Public exhibition d ❑ Loan or exchange programs b ❑ e El Other Scholarly research c ❑ Preservation for future generations 4 Provide a description of the organization's collections and explain how they further the organization's exempt purpose in Part XIII 5 During the year,did the organization solicit or receive donations of art, historical treasures or other similar assets to be sold to raise funds rather than to be maintained as part of the organization's collections ❑ Yes ❑ No Escrow and Custodial Arrangements. Complete If the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X line 21. is Is the organization an agent, trustee,custodian or other intermediary for contributions or other assets not included on Form.990, Part X7 ❑ Yes ® No b If"Yes,"'explain the arrangement in Part XIII and complete the following table Amount c Beginning balance 1C d Additions during the year id j e Distributions during the year le ! f Ending balance if 2a Did the organization include an amount on Form 990, Part X, line 21,for escrow or custodial account liability? . . . ❑ Yes © No b If"Yes,"explain the arrangement in Part XIII Check here if the explanation has been provided in Part XIII . . . . ❑ Endowment Funds. Complete If the organization answered "Yes" on Form 990, Part IV, line 10. (a)Current year (b)Prior year (c)Two years back (d)Three years back (e)Four years back la Beginning of year balance . . b Contributions . . . c Net investment earnings, gains,,and losses d Grants or scholarships . . e Other expenditures for facilities and programs f Administrative expenses . . . . g End of year balance 2 Provide the estimated percentage of the current year end balance(line 1g, column (a)) held as a Board designated or quasi-endowment 11, . F b Permanent endowment 1 c Temporarily restricted endowment 0- The percentages on lines 2a, 2b, and 2c should equal 100% 3a Are there endowment funds not in the possession of the organization that are held and administered for the I` organization by Yes No (i) unrelated organizations . . . . 3a(i) (ii) related organizations . . . . . . . . 3a(ii) b If"Yes"on 3a(n), are the related organizations listed as required on Schedule R7 . . . . . . . . 96 4 Describe in Part XIII the intended uses of the organization's endowment funds Land, Buildings, and Equipment. Complete If the or anlzatlon answered "Yes" on Form 990, Part IV line 11a. See Form 990 Part X line 10. Description of property (a)Cost or other basis (b)Cost or other basis(other) (c)Accumulated depreciation (d)Book value (investment) f.a Land b Buildings . . c Leasehold improvements d Equipment . . . e Other . Total.Add lines la through le(Column(d)must equal Form 990, Part X,column(6),Irne 10(c)) ► Schedule D(Form 990) 2018 Schedule D(Form 990)2016 Page 3 Investments—Other Securities.Complete If the organization answered"Yes"on Form 990, Part IV,line 11b, See Form 990 Part X line 12, (a)Descnption of security or category (b) (c)Method of valuation (including name of security) Book Castor end-of-year market value value (1)Financial derivatives . . . . . . . (2)Closely-held equity interests , (3)Other (A) (B) (C) (D) (E) (F) (G) (H) Total.(Column(bf must egvat Form 990,Part X,mt(9)line 12) p Investments- Program 12elated. Complete If the organization answered'Yes'on Form 990,Part IV, line 11c.See Form 990,Part X, line 13. (a)Description of mveatment (b)Book value (c)Method ofvaluation Cost or end-of-year market value (i] (2) {3) (4) (5) (6) (7) - i (97 — Total.(Column(b)must equal Poem 990,Part X,aol(8)fine 13) p 1:MINN Other Assets.Complete if the organization answered'Yes'on Form 990 Part IV,line Sld See Form 990 Part X line 15 (a)Description (b)Book value (i)Deposit - 4,443 (2) I (3) (4) (5) (6) (7) (8) (g) Total.(Column(b)must equal Form 990,Part X,col(B)line 15) p 4,443 Other Liabilities.Complete If the organization answered'Yes'on Form 97 part IV,line Ile or Ilf, See Farm 990 Part X line 25, 1. _ -(a)Description of liability (b)Book value - (1)Federal income taxes .(2) (3) (4) (5) (6) (7) (9) Total.(Column(b)must equal Foam 990,Paid X,ool(ft)line 25) - p - 2.Inability for uncertain tax positions In Part XIII,provide the text of the footnote to the organlzatlon's financial statements that reports the organization's liability for uncertain tax positrons under FIN 48(ASC 740) Check here if the text of the footnote has been provided in Part XIII ❑ - Schedule D(Force 990)2018 Schedule D(Form 990)2018 Page 4 Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' on Form 990 Part IV line 122. 1 Total revenue, gains,and other support per audited financial statements . . . . . . 1 2 Amounts included on line 1 but not on Form 990, Part VIII, line 12 a Net unrealized gains(losses)on investments . . . 2a b Donated services and use of facilities . 2b c Recoveries of prior year grants . 2c d Other(Describe in Part XIII) . . 2d e Add lines 2a through 2d . . . . . 2e 3 Subtract line 2e from line 1 . . . . . 3 4 Amounts-included on Form 990, Part VIII, line 12,but not on line 1 a Investment expenses not included on Form 990,Part VIII, line 7b 4a b Other(Describe in Part XIII) . . . 4b c Add lines 4a and 4b . . . . . . . . . . . . . . . . . . . . 4c 5 Total revenue Add Imes 3 and 4c. (This must equal Form 990, Part I, line i2 ) . . 5 Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a. 1 Total expenses and.losses per audited financial statements . . . . . . . . 1 2 Amounts included on fine 1 but not on Form 990, Part IX, line 25 a Donated services and use of facilities . . . . . . . . 2a b Prior year adjustments . . . . . . . . . . . . . 21b c Other losses . . . 2c d Other(Describe in Part XIII) . . . . . . . . . . . . 2d e Add lines 2a through 2d . . . 2e 3 ' Subtract line 2e from line 1 . . . . . 3 4 Amounts included on Form 990, Part IX, line 25, but not on line 1: a Investment expenses not included on Form 990,Part VIII, line 7b 4a b Other(Describe in Part XIII) . . . . . . . . . . 4b c Add lines 4a and 4b . . 4c 5 Total expenses Add lines 3 and 4c. (This must equal Form 990,Part I,line 18 ) . 5 Supplemental Information Provide the descriptions required for Part II, lines 3, 5,and 9, Part III, lines la and 4, Part IV, Imes lb and 21b, Part.V, line 4, Part X, line 2, Part XI, lines 2d and 4b, and Part XII, lines 2d and 4b Also complete this part tc provide any additional information Return Reference Explanation Schedule D(Form 990) 2018 page 5 990)201$ COOtintied) p1as$t�an 994)24�$ t2t ZrifiQr��tpf e t Sch�U1� �Fo c✓VPPteme� R rn Re{erence efile GRAPHIC pri t- DO NOT PROCESS As Filed data - DLN: Schedule L Transactions with Interested Persons (Form 990 or 990-EZ) 0, Complete if the organization answered"Yes"on Form 990, Part IV, lines 25a, 25b,26, 27,28a,28b,or 28c,or Form 990-EZ,Part V, line 38a or 40b. ®� 0,Attach to Form 990 or Form 990-EZ. ►Go to www.frs.aov/Form990 for the latest information. Deginrunen[of the Tremun Open to Public InternnlReNenue Son ice Inspection Name of the organization Employer identification number DISCOVERY COUNSELING CENTER Excess Benefit Transactions (section 501(c)(3),section 501(c)(4), and 501(c)(29)organizations only) _ Complete if the organization answered "Yes'on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V,line 40b 1 (a) Name of disqualified person (b) Relationship between disquahfted person and (c) Description of (d) Corrected? organization transaction Yes No I i I I t 2 Enter the amount of tax incurred by organization managers or disqualified persons during the year under section 4958 . . . IS 3 Enter the amount of tax, if any, on line 2,above,reimbursed by the organization. . . A $ Loans to and/or From Interested Persons. Complete If the organization answered "Yes" on Form 990-EZ, Part V,line 38a, or Form 990, Part IV,line 26, or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22 (a)Name of (b) Relationship (c) Purpose (d) Loan to or from the (e)Orlginal (f)Balance (g)In (h) (i)VVritten interested person with organization of loan organization? principal due default? Approved by agreement? amount board or committee? To From Yes FNQ Yes No Yes No (1) Executive Operating X 20,000 10,093 No Yes No Larry McElvain Director expenses I Total 6 $ 10,093 Grants or Assistance Benefiting Interested Persons. Complete if the or antzatlon answered "Yes' on Form 990 Part IV line 27. i (a) Name of interested person (b)Relationship between (c)Amount of assistance (d)Type of assistance (e) Purpose of assistance interested person and the organization For Paperwork Reduction Act Notice,see the Instructions for Form 990 or 990-EZ, Schedule L(Form 990 or 990-EZ)2018 _ Page 2 (e�c�liartn9 ct�on of s song. I! 1�ne 28a,2$dl aes Peon of transa 23 or9ayenQes re o terestea Fes gg� aunt°f g9p_E�)2�ia =nVplrr�n9 d„,des„ an F°rm ��t ap action L EForrn gg�or ?r�nsa`t�o?at�an ansW(b)Pelatltere ed Schedule Bugt ,f the or on 1'e erson and one me of,nterested Pe P ar9an�Zaa tad Na co s gg or gga,t212a�$ see nstru'tran p0e {F°ram a an Schedule� Exp1a�'�ion . 5ch� V�5'Clans ati00 orj5es to 4 entao 1 °r S ion far res forrn S�pplemditionel jn Provide ad Return r"� ere of 00 file�Data~ O� c@� pRocEs� Q�m� �t� Q,resMse'IdW ^af itef'��m 01M. n � A 14 An fo�°�'tta�to Cov@de a u��`�S @nfacras gsnP\a PN�G tint �C��PE to p`oy@ a-'fa r tO°q90 fay t\+e @ate efe1�Gam' plete 990 or r pttaaY parr �`'-0 fors++ �'��@��gg®- r Go to �Qc�►gg aft neloft r�Y 4 ,entt�R�'� 6 CENTER i fi� ��t �xp@a o�Go��Y Go�Nsc->3 gti4�'�e�e�ta g0 S�h�aUee 0 ��oatta of ptteototg Retelfn of V7t\\Si'Wt�N a Refete�oe e pate `� b 11 i 01 VAT A��''6�E Fteieteo DaGVCA !ec►e 19 Discovery Counseling Center (NEW) Eligibility Checklist (staff use only) Eligibility YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/project/event Identify how the funds will be used to benefit the Cupertino X community Be awarded only once per project X Information provided did not identify specific funding allocations and/or funding For specific needs,not on going,operational costs X was designated for ongoing operational costs. Have more than 75%of the requested funds allocated for direct X 26%or more of the requested funds were allocated toward expenses not directly service costs versus administrative costs tied to the proposed program/event/project(i.e.:organizational staffing costs) Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only NA submit one application Proceeds generated from the funded activity may only be used for the conducted activity NA admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved X Fees will be charged for the requested program/event/project.Approval required by Parks and Recreation Commission 1from Parks and Recreation Commission. City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Community Funding Grant in the past? Yes No If, Yes, when? Legal Name of Organization:Buddhist Tzu Chi Medical Foundation Web Address; a ww_tzuchimedical.us Mailing Address: City: am ra Zip: 91801 Prone President/Executive Director:Steven Voon Title: Executive ice President Email: steven.voon@tzuchimedical,us Telephone Number: Contact Person: Yuaner Wu RN, PhD, MPH, CNSTitle: Milpitas Dental Mobile Clinic Coordinator Email Address: Telephone Number 3E€:_fI0Pd 2: N0oN41ROFiT INFORMATION 501(c)(3)? * Yes 0 No Year Established 1993 Federal Tax ID: Fiscal Sponsor Name; Buddhist Tzu Chi Medical Foundation Fiscal Sponsor Address: City: Alhambra Zip: CA Phone: 91801 :JI:MATiO;• Total Organization Budget: $7,000,000 Total# of Board Members: 13 Total#of stafF: 55 Total# of Volunteers: 250 Mission Statement: We provide patient-centered rnedical care with compassion to underprivileged individuals regardless of religion, age, gender, ethnicity or ability to pay. Our founder, Dharma Master Cheng Yen, once said: 'Among the eight sufferings of life, illness is the most painful. With the aim of patient-centered medical care that respects patients as teachers, Tzu Chi's medical team will shoulder the responsibility of caring for people's lives and must ensure proper care of the body, mind, and soul of the patients'. We will go forward in our commitment to heal as many underserved communities around the world as we can-with as much heartfelt diligence and compassion as possible. ('Tzu Chi'means'Compassion Relief) Brief Description of Organization: Tzu Chi Foundation is a global non-profit organization whose compassion-in-action principle impacts over 100 countries worldwide. Now into its 55th year, the organization remains steadfast in serving through four core missions: Charity, Medicine, Education, and Humanistic Culture. Tzu Chi Milpitas Mobile Clinic belongs to an outreach program known as Tzu Chi International Medical Association (TIMA) which is supervised by Tzu Chi Medical Foundation USA.The Milpitas Mobile clinic is operated by four San Francisco Bay Area TIMA Chapters in the Northwest Regional Office, Each TIMA Chapter collaborates with Local non-profit organizations to provide free medical, dental, vision care and oriental medicine consultation for undersenred communities. In San Francisco, we have been providing dental care for the residents of Delancey Street Foundation and Alice Griffith community since 2014. In Milpitas,we provide free dental care and oriental medicine consultation on the second and fourth Monday. Brief Description of Services Provided: Tzu Chi Milpitas Mobile Clinic collaborates with community partners to host a health fair, Based on population needs, we provide the following services free at no charge: western medicine consultation, oral exams, oral health education, diagnostic imaging, dental cleanings, fillings and extractions, vision exam,oriental medicine consultation,and chiropractic service. In addition to health fairs, each TIMA Chapter also hosts health seminar's, workshops and support groups to promote health awareness and community health. In 2020, though alf medical outreach events had come to a halt due to the COVID-19 pandemic, Tzu Chi medical quickly mobilized a team of volunteers in March 2020 to help deliver and distribute PPE (personal protective equipment)and sanitization care packages to health-care facilities, migrant farmers, and homeless shelters.Io- date,we have distributed 310K surgical masks, 32K Ng5 masks, 2.81K protective coveralls,8.3K gaggles, 3K isolation gowns and i K face shields SECTION 4: GRANT REQUESTS 1. Program(Project/Event Name: Healthy Cupertino Health Fair 2. Calais)and/or duration of program/project/event(if applicable):December 11, 2021 from 9 am to 3 not(dale subjected to change per COVID-19 infection rate) - 3. Total program/project/event budget: $7,400 4.Requested Amount: $7.400 Percent of total program/project/event budget: 100% 5.ProgremlProject projected Income: $7,400 Percentage of your organization's projected Income: 100% 8.Type of Request: ❑Capital Improvement 0 Program Support 5Event 0One-time project 0Other: 7. This grant will fund a(n): 0 Existing program/projecl/event;established in(year) 0 New program/projeCVevent 8. Describe the purpose of requested funds and the services that will be provided: We propose to use the grant to host a day of community health fair with free medical services to the financially challenged Cupertino residents. In this health fair,we plan to offer free blood pressure check,oral exam, oral diagnostic imaging, oral health education,dental filling, and extraction and,oriental medicine consultation and treatment.The requested fund will be used to cover the facility rental in Cupertino, general and malpractice insurance coverage, medical and dental supplies,administrative expenses, and vegetarian meals and drinks for general volunteers and health care volunteer providers.Tzu Chi volunteers and doctors work diligently to ensure members of the community receives the lave and care that they need. Together with this grant, Cupertino community will continue to become happier and healthier. 9. Please provide a line item breakdown of how the funds will be used in the categories below. If a category is not a licable,Put$0: Admin Staff $8001 Materials/Equipment $3,2001 c Entertainment $ d RoomA/enue Rental $2,00 Other Professional Services Malpractice insurance$1400 $70 Other $ otal $7,40 10.Explain how the request aligns to City mission and values: The Mission of the City of Cupertino is to provide exceptional service, encourage all members of the community to take responsibility for one another, and support the values of education, Innovation and collaboration.To support City mission and values, Tzu Chi Milpitas Mobile Clinic will be collaborating with West Valley Community Center (WVCS)to host a community health fair. Dental procedures will be provided in an Innovative way on the mobile dental van. One-on-one health education will be provided by licensed health professionals. 11.Describe how the program/projecUevent fills a community need.Who Identified this need?What other similar project/program/event exists to serve Cupertino residents? How is your proposed project/program/event unique from similar projecis/programs/events or how do you collaborate to avoid duplication? In order to carry out Tzu Chi's Medical Missions, the Milpitas Mobile Clinic brings the needed health care to the underserved populations. Free,good quality dental care services are especially very hard to come by in the San Francisco Bay Area. Since 2010, Milpitas Mobile Clinic has hosted medical outreaches at many cities including Magalia, Oroville, Ukiah, Santa Rosa, San Francisco, Oakland,Milpitas, Fremont, and Central Valley. Since 2018,Tau Chi has offered three free dental outreaches to East Palo Alto(EPA)residents.Our partners Ravenswood City School District, Boys and Girls Club of the Peninsula, and the Children's Health Council have witnessed Tzu Chi working to provide our services to the residents on multiple occasions.They invited Tzu Chi to the EPA community to provide dental care for low-Income Mexican families.They helped find the best location for the Mobile Dental Clinic, and reached out calling the low-income families to come for a free dental checkup. 12.Who will be served by this grant? The grant will be used to serve Cupertino low-income residents referred by West Valley Community Services (WVCS). a)Number of individuals total: 40 b) Number of Cupertino residents: 40 c)Particular community groups: Cupertino low-income residents referred by West Valley Community Services(WVCS). d)Will the program/projectlevent be available to the entire community/public or are there any eligibility criteria? Our program goal is to serve underserved communities within Cupertino with referral by West Valley Community Services(WVCS). Our criteria includes recipients of Metli-Cal, Calfresh or Supplemental Security Income(SSI). e)WIII there be a charge or fee for the programlproject/event(If applicable) This event Is free at no charge to the participants of the Healthy Cupertino Health Fair. fl What outreach methods does your organization use to promote the program/project/event(if applicable)? Milpitas Mobile Clinic will be collaborating with West Valley Community Services(WVCS)in promoting this event among the recipients of food pantry and low-income housing residents. ' 13. Describe how the funds will be used to benefit or Impact the Cupertino community: The funds will be used to provide free medical,dental and oriental services to financially challenged Cupertino residents.Our unique program will have a significant impact on the health of low-income Cupertino residents.Tzu Chi volunteers and doctors work diligently to ensure members of the community receive the love and care that they need.Together with this grant, Cupertino community will continue to become happier and healthier. 14. Demonstrate that the member implementing and managing the program/project/event have adequate experience: Milpitas Mobile Clinic has been blessed to have a group of very dedicated health care providers and medical volunteers. Now into the eleventh year,CH Wong DDS,S. Wang DMD, and L Pang RDH have been leading our dental program. - In addition, V Wu, RN, MPH, PhD has been the Event Coordinator for more than twenty years since 1999. In 2019 alone,we conducted 19 medical outreaches and 23 fixed location free dental clinic services at Milpitas,with a total 42 events, 1511 patients sewed with 4328 service encounters. 15.How will success of the programfprojectmvent be measured?: Our outreach success will be measured quantitatively and qualitatively.Quantitative measures are event outcomes including numbers of clients being served,vital signs checks,western medicine consultation, oral exam, oral health education,oral x-rays,oral hygiene procedures, tooth fillings,tooth extractions, oriental medicine consultations, acupuncture treatments, and therapeutic massages.Qualitative measures include satisfaction of the professional volunteers, general volunteers and recipients of our care. From professional volunteers,May enjoy the most when their clients thank them for answering their health related question, appropriately addressing their health issue, relieving their toothache, alleviating their bodily soreness or muscular pains.Typically, our general volunteers will ask each client about his/her experience with us and noted in his/her medical records.Ultimately, our event goal is to let everyone have an enjoyable and meaningful experience. 16.Will more than 75%of the requested funds go towards direct service costs versus administrative costs? 0 yes 0 No 17.WIII you collaborate with other organizations to deliver the program/project(event funded by this grant?If so, which organizations? We will be collaborating with the City of Cupertino and West Valley Community Center to host the'Healthy Cupertino Health Fair'in Cupertino, GA. 18.If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants, please describe this support: No, the Milpitas Mobile Clinic has never received any financial or in-kind support from the City of Cupertino. 19.Does your organization anticipate receiving additional financial or In-kind support from the City of Cupertino outside of Community Funding Grants for this type of program/proJectlevenl(e.g.fee waivers)? If so, please describe this anticipated support: No, the Milpitas Mobile Clinic will not be expecting to receive any additional financial or ii ind support from the City of Cupertino. 20. It you are a multiyunsdictional organization, describe any funding requested from other agencies/organizations in regards to this program/projectfevent request. Indicate whether the funding was granted, denied,or is still pending: No, the Milpitas Mobile Clinic has not requested any other funds from other agencies or organization for this event. 21.How would you fund the program/projectmvent if you do not receive the requested funding?: All the events hosted by the Milpitas Mobile Clinic have been financially supported by donors,friends,families of Tzu Chi Medical Foundation. If we do not receive the requested funding,we will continue to seek donations to support the proposed event. SECTION 5: PRIOR FUNDING 1. If you received a Community Funding Grant in prior years,indicate the amounts for each year and describe how those funds were used: We have not applied the Community Funding Grant in the past years. This is our first application. 2. If you received a Community Funding Grant last year: a. Please provide a line item breakdown of how the Community Funding Grant was used last year in the categories below. If a categmy is not applicable,put$0: 1.Admin Stag $ ii.Materiels/E ui ment $ iii. Entertainment $ iv. Roorril Rental $ .Other Professional Services$0 $ i. Other$0 $ Total $ b.Who was served by the grant last year? N/A I.Number of individuals total: 0 it.Number of Cupertino residents:0 !it.Particular community groups N/A Iv.Was the program/project/event available to the entire community/public or are there any eligibility criteria? N/A v.Was there a charge or fee for the program/project/event(if applicable)? N/A vi.What outreach methods did your organization use to promote the program/projectlevent(if applicable)? N/A c.Was the program/project/event successful?Please indicate how success was measured: N/A 3.Please indicate any additional funding received last year from other sources and provide your financial statement if available: N/A Attachments:Attach your financial statment, and any other helpful information about your project. 2019-TCMF-AnnualRepod.ptlf Supplementary o�ertino Grant 2021.docx Program Manager Signature Milpitas Dental Mobile Clinic Coordinator Date Signed 01/30/2021 A 1, Y f A Y , t �1 F 2019 edicalF rZucni Annual Report Medical Foundati' p Serving with Compossio Buddhist Tzu Chi Medical Foundation a,..:5 .. _ .:. About Tzu Chi stablished in Taiwan in 1966,the Buddhist Tzu Chi Foundation is an international humanitarian aid sea I_ organization that has provided compassionate emergency and long-term aid to 102 r countries across five continents.Tzu Chi endeavors to relieve the suffering of those in need, and create a brighter world for all through innovations and charity work in the fields of medicine,education,disaster relief, environmental protection,and humanistic culture.Tzu Chi s global reach is strengthened through collaborative efforts with partner organizations,such as the American Red Cross (ARC),United Nations Economic and Social Council (UN ECOSOC),the National Voluntary Organizations Active in Disaster(NVOAD), and InterAction. About Tzu Chi Medical Foundation USA Established in 1993,the Tzu Chi Medical Foundation provides holistic and integrated healthcare services across the United States, to financially disadvantaged residents regardless of age,race,sex,or religious affiliation.With permanent clinics in Alhambra,South El Monte, and Wilmington, California,we offer exceptional care to underserved populations in those regions. We also host free,periodic large-scale local and international medical outreach events in the U.S.,Latin America,and the Caribbean,in addition to providing mobile dental and vision care programs,support groups,and preventive health education.Our volunteer doctors,nurses,and other healthcare professionals and general volunteers serve vulnerable communities with compassion and care. Our Mission We provide affordable and charitable patient-centered health care for the wellness of the underserved. Our Vision To provide medical aid while inspiring love and compassion in both those giving care and those receiving it. tzumimed'iLai.us 1 A Message From Our CEO Dear Friends, The year 2019 was a busy one for the Tzu Chi Medical Foundation,on manyfronts. The 5th TIMA Global Forum,held from March 29 to 31 in San Dimas,California, was the first international event held in the United States at Tzu Chi USA§national headquarters.More than 500 members,speakers and VIP guests from 17 countries attended the conference,which was titled"Enlightened Wellness:Body,Mind,Spirit" The entire staff at the headquarters'campus and many volunteers across the U.S. pitched in to make this event possible.It was a great success that unified our staff and volunteers and attracted new friends to join us. In March 2019,we handed over the eighth and ninth Tzu Chi Vision Mobile Clinic vans to Tzu Chi USAs New York chapter.These specially outfitted vehicles have officially started providing services for New York City elementary school students.With a grant from the Kaiser Permanente Foundation,we placed an order for a Dental Mobile Clinic van as well,which we scheduled to start providing services for migrant workers in 2020. Tzu Chi Medical Foundation(TCMF)and the UCLA Center for East-West Medicine (CEWM)followed through on a mutual desire to form an alliance,whereby: CEWM shall create an integrative educational program,to train TCMF healthcare professionals as seed trainers,who will then disseminate the program at our clinics to benefit patients.Panda Charitable Foundation agreed to provide a matching grant to support our participation in this alliance,which just completed its first half-year of existence.All staff is in place,and things have gone smoothly regarding the completion of the first part of all courses.We hope to incorporate the program into our clinics in 2020.Thank you,Panda Charitable Foundation,for your generosity. We expanded our international medical missions in Ecuador and Mexico in 2019.TIMA (Tzu Chi International Medical Association)provided medical services during over 15,877 patient visits throughout 20 medical outreach events.We not only took care of people's physical needs but also offered moral support,resulting in smiles that express a sense of hope. We are setto applyforthe status of Federally Qualified Health Center(FQHC)by March 2020 and expect to receive approval by October of that year.This new status will help TCMF reach the goal of sustainable development. I want to express my deepest gratitude for all our donors,sponsors,partners,medical professionals,and logistics volunteers whose support and dedication have made us strong today.We've accomplished a great deal together in this busy year.With the steadfast efforts of our staff and volunteers,we are sure to continue on this path of success in the coming year. Gratefully, 1 William Keh,M.D. Chief Executive Officer Tzu Chi Medical Foundation Delivery of Care Domesticand Permanent Clinics MobileClinics Healthy Community International Medical Programs Outreach (TIMA) Tzu Chi's first clinic Tzu Chi's mobile clinics Tzu Chi's Healthy Tzu Chi International was established in have delivered high- Community Programs Medical Association Alhambra,California in quality healthcare provide preventive (TIMA)is an organized 1993. services to communities health services to global service network around the country at thousands of individuals that consists of licensed Today,we have no cost for 19 years. in need. medical professional and three permanent logistics volunteers. clinics in California Afleetofnine These holistic programs -in Alhambra, mobile clinics serves are designed to cultivate Volunteer expertise South El Monte,and underprivileged healthier lifestyle choices is utilized to facilitate Wilmington. communities in within communities. patient-centered medical Califomia,itsservices services to vulnerable Services provided recentlyexpandingto Services include healthy populations affected by include medical, New York and Las Vegas. living programs,health disasters and poverty dental,and vision workshops,educational locally and worldwide. care;traditional Services provided outreach,cancer Chinese medicine include medical,dental, awareness programs, Services provided include (TCM);acupuncture; and vision care,as well patient support groups, medical,dental,and psychotherapy;and as cancer screenings. and Integrative East- vision care;traditional Healthy Community - West Medicine. Chinese medicine like Programs. acupuncture;and health education. Areas of Service Traditional Fj — Medical Dental Chinese Vision Provide low-to no- Administeraccessto Provide low-cost. Offer low-cost cost comprehensive affordable dental care high-quality traditional optometryand primary care services for local residents,low- Chinesemedicine ophthalmology care to to safeguard patients' income individuals,and treatments RCM)to promote eye health and overall health. underserved Populations. help patients recover vision function. Deliverquality Services include general from ailments and medical care including dentistry,dentures.and promote overall Services include internal and family oral hygiene education. well-being.Services vision testing,and medicine,pediatrics, include acupuncture, comprehensiveeye immunizations, acupressure,cupping, examinations consisting women's health, Tui-Na,herbal of diagnosis and minor surgery,and Gl remedies,therapeutic treatment programs. endoscopy. exercises,and dietar y Prescription lenses are regimens. alsooffered. tzuchimedical.us 3 Summary of Operations 2019 was a significant year for the Tzu California,with recent expansion to Chi Medical Foundation.To start,our New York a nd Las Vegas.With the support three permanent clinics-in Alhambra, of2,028 healthcare professionals and 5,044 South El Monte,and Wilmington-offered general volunteers,we offered 313 medical 21,476 consultations and treatments.To outreach events and mobile clinic setups provide better quality and sustainable nationwide,providing 11,869 consultations healthcare,the clinics also raised their and treatments,together with free medication. operational standards to comply with the requirements for becoming a Federally Over the participants from hi countries Qualified Health Center. joineddthesoci TIMA(Tzu Chi Inter national Medical Association)Global Forum,the first Throughout 2019,we held 122 health international conference organized by the education workshops nationwide Tzu Chi Medical Foundation held in the United and participated in 40 health fairs States.Not only were current and emerging that provided 6,331 consultations medical trends amply discussed,but the and treatments to underprivileged achievements accomplished by TIMA du ring communities.We received recognition - domestic and international medical missions from partners,such as the City of Hope were equally shared. and UCLA Center for East-West Medicine, Seeds of collaboration and service continued the latter resulting in a grant award and flourishing cooperation regarding to be planted and to grow in Mexico and Integrative East-West Medicine programs.- Ecuador,fostering local medical talent while providing healthcare services to Our mobile clinics and domestic medical 15,877 patients in need of care.Overall,our outreach have continued to bring operations in 2019 proved to be sustainable, healthcare services to the doorstep of establishing a solid building block for our underinsured and uninsured people across activities in 2020. 00000 • our three permanent clinics- e we offered 313 medical • we provided healthcare in Alhambra,South El Monte, outreach events and services to 15,877 and Wilmington-offered mobile clinic setups patients in need of care in 21,476 consultations and nationwide,providing Mexico and Ecuador. treatments. 11,869 consultations and treatments. 4 1 Tzu Chi Medical Annual Repaid:2D19 2019 Summary of Operation & Patient Demography Permanent Clinics 4% 1% 4 Patient Service Counts: 21,476 Al Patient Head Counts: 7,833 —g UU ■ Asian:72% ' White (including Hispanic): 12% ■ Black/African American: 1% 12% z% Unreported /Refused to report:4% Other(including more than one race): 11% 16% Mobile Clinics/ 1% Medical Outreach — ' -' Patient Service Counts: 26,032 O 11 Patient Head Counts: 11,869 .fill- Asian: 16% 7;; ■ White(including American: ■ Black/African American:7% ..1: Other(including more than one race): 1% Unknown:5% t�ucAimMiral.us 5 PERMANENT CLINICS m41 BUDDHIST TZU CHI MEDICAL CENTEMedical Acupuncture De 1 = 019 was a year of riding on Tzu Chi treating patients'symptoms,but went Medical Foundation's sustainable above and beyond to provide preventive building blocks in the provision of health education combined with healthy healthcare services for underinsured and community wellness programs,all part of uninsured communities, primarily through holistic approach that addresses not only its permanent clinics in Alhambra,South El the body but the heart and mind as well. Monte, and Wilmington,California. Furthermore,in pursuit of the utmost quality The three clinics-offering medical,vision, in facilities,care,and safety,the clinics also dental,and mental health care,along decided to rise to the challenge of meeting with acupuncture and pediatrics-provided federal standards and requirements for 21,476 consultations in 2019.The healthcare becoming a Federally Qualified Health professionals at the clinics didn't stop at Center(FQHC) Look-Alike. 6 1 Tzu Chi Medical Annual Report 2019 Preparations have gone forward, including and empower underserved areas through the complete review of all policies high-quality patient care services and and procedures,ensuring that we are community initiatives. providing the services that suit our patient demographics,and additional training and Looking ahead,Tzu Chi Medical Foundation developmentfor our clinic staff. also hopes to maintain higher levels of sustainabilityand patient-centered care All these efforts and initiatives wouldn't as a result of enhanced financial support have been possible were it not for our provided by the Health Resources devoted providers,and experienced and services Administration (HRSA). support staff,who continue to raise the bar Traditionally,our clinics relied on donations higher to provide patient centered care. to keep out of pocket fees low for our Another important factor behind the underinsured and uninsured patients. foundation's applicationforFQHC In the future,the donations will be able to support the expansion of our reach Look-Alike designation is that this and capacity to offer even more medical aligns perfectly with Tzu Chi Medical services, health programs,and education Foundation's mission:To relieve suffering with in the communities we already serve by providing medical care to those and beyond. who lack the means to pay.Becoming a Federally Qualified Health Center Look-Alike will enable our clinics to In2O19our permanent clinics address health care access disparities provided 21,476 treatments to those in need J 8,540 Patient Visits (Medical) 67 Patient Visits(Vision) r 5,064 Patient Visits(Dental) r\ VII' 7,705 Patient Visits(Acupuncture) 100 Patient Visits(BCED P)* A Acupuncture treatment to help safeguard patients'health. " Breast Cancer Early Detection Program r:ucmme !CADS 1 7 i f > Dr.Stephen Denq listens _ to a patient's heart during a routine checkup. Y Chinese Medicine doctor, Alex Vi Hsien Lai,treating a patient with care :6 ILI y S Tzu Chi Medical Annual Report 2019 1 Y y v COW no MOBILE ° CLINICS A Tzu Chi Vision Mobile Clinic Tzu Chi Medical Foundation's mobile community partners,and donors tojoin the clinics have been bringing health force.The See 2 Succeed project, a school- care to the doorstep of people in based vision care initiative formed in 2015 need for more than 19 years.Our fleet of on behalf of children from underserved nine mobile clinics offers comprehensive communities in California's Central Valley,is medical,dental,and vision care,as well one example of resulting collaborations. as cancer screening services.The mobile clinics also participate in large-scale As partof this nonprofit partnership,Tzu multi-day community medical outreach Chi Medical Foundation's Vision Mobile events and health fairs across the country, Clinicsgo to schools in 18 school districts reaching underserved communities that and provide studentswith freefull eye exams face barriers to health care access. and prescription glasses as needed during the visit.Children who benefited from the The complementary services of mobile project are doing much better in school due clinics and domestic medical outreach,in to their improved vision and confidence. conjunction with health education and The success of See 2 Succeed in Fresno also community volunteerism,have built led to full funding support and the project's solid platform for attracting volunteers, extension to local community schools in New York and Las Vegas in 2019. 10 1 Tzu Or Medical Annual Report 2019 �L Our Mobile Vision Care Garners Support Near and Far s. M.,a patient at a Tzu Chi Vision Mobile Clinic, heard the story of how Dharma Master Cheng Yen built the first Tzu Chi Hospital in Taiwan and was touched. Learning about Tzu Chi's bamboo banks,in which people save to help those in need,and discovering that 1 donations support the services offered 1 by our mobile clinics,she was inspired to contribute. And so,Ms.M.asked to re-use her old A A patient proudly holds her new glasses as she eyeglass frames with her new prescription, poses for a picture with Dr. Lina Lin, rather than accepting new ones provided by the clinic,to help Tzu Chi preserve some of its precious resources for those who require more assistance than she did.Although she was concerned that she did nt have much to offer monetarily,Ms. M.was stil I able to help through her thoughtfulness,benefiting someone in need. 9T "i tl A The See 2 Succeed vision program is a local A Thanks to the See 2 Succeed program,a young nonprofit partnership that works with patient shines a smile after seeing his new glasses Fresno County schools to offer free eye for the first time. exams and glasses to local children. Mchimedicalms 1 11 f( I, , r o Dr. Harry Shaw,a veteran volunteer,brought his _ associate to provided treatment at Azusa Myanmar Monastery through Dental Mobile Clinic. > Tzu Chi's Vision Mobile Clinics also serve seniors. 12 1 Tzu Chi Medical Annual Report 2019 Dentists on Wheels One care recipient,Isabel Arenas,shared Bring Smiles Back that"if I hadn't found this truck[Tzu Chi Dental Mobile Clinic],I could've lost my and Improve Lives tooth because I don't have the means to go[to the dentist].The truth is,this is Life can be hard without good health. marvelous work,sent from the heavens. Imagine having a toothache, but It's incredible.And the doctor who treated being unable to visit the dentist and me has the hand of an angel.Seriously, having to endure constant,searing pain. thank you. It's something l can't explain. Tzu Chi Medical Foundation's Dental They've helped us immensely" Mobile Clinics provide services to those living on the streets in Lincoln Heights, Javier Alvarez is another care recipient, an impoverished suburb in Los Angeles who had dental issues since his front teeth County. had lots of gaps in between and cavities. He said,"I had a lot of problems eating.The food got stuck in my teeth because I didn't have fillings.Now that I have[the fillings], it fixed the problem,and I can smile better." Tzu C111 Mobile #env, � v A Tzu Chi's mobile medical services,including those of the dental clinic, bring smiles to the faces of even the youngest patients. nuchimedicaLus 1 13 TZU CHI (" INTERNATIONAL . ju 41 2019 AA GLOBAL FORUM TZU CHI USA :. i7? p�J Inspired by Dharma Master Cheng Yen's with over three million healthcare services mission to safeguard and protect life and given to underprivileged populations health with love,Tzu Chi International worldwide. Medical Association (TI MA)was established in 1996 as the embodiment 2019 was a significant year for TIMA USA, of altruistic care and recognition of the whose members provided free health person behind the patient.Since then,over care straight to the heart of communities 10,000 licensed medical professionals- most in need via mobile clinics,domestic including doctors,dentists,acupuncturists, outreach,and international medical nurses, pharmacists, and medical missions.Furthermore,the year marked technicians-have offered their services notonlythe first time thatthe TIMA as volunteers.To date,they have provided Global Forum took place in the U.S., but it free medical care in over 50 countries, was alsothe 26th Anniversary of the Tzu Chi Medical Foundation. 14 1 Tzu Chi Medical Annual Report 2019 Over 500 healthcare professionals from Barger presented a Proclamation of 17 countries gathered at the TIMA Global Congratulations to Tzu Chi USA and Tzu Chi Forum,entitled"Enlightened Wellness: Medical Foundation volunteers.Supervisor Body, Mind,Spirit,"and held in San Dimas, Barger has observed Tzu Chi volunteers California,from March 29 to 31.Thefocus, providing affordable medical care for discussion,and sharingof integrated and everyone,including new immigrants in synergized medical ethics efforts,the Alhambra for 26 years,beginning in 1993 balance between academia and practice, when Tzu Chi established its first free the combination of eastern and western clinic.As she presented the proclamation, therapeutic approaches,and the actions she stated that"Government alone can't and footprints of TI MA and Tzu Chi help. It takes the work of groups across the Medical Foundation, were the highlights of world to really help (people) in their time of this remarkable forum. need"TI MA is grateful to be among those During the conference,Los Angeles groups,providing vital healthcare services internationally,with dedication and love. County Supervisor Kathryn ` t 3_ - �- < Los Angeles County Supervisor Kathryn Barger presents - � a proclamation of '� Congratulations to Tzu Chi USA and Tzu Chi Medical Foundation for its accomplishments. >TI MA representatives from Latin America,including Tzu Chi Mexico (; l and Ecuador volunteers,attend the TI MA Global Forum, P 1 Vito, e IL DOMESTI MEDICAL OUTREAC ith the complimentaryservices of To meet the growing needs of uninsured and mobile clinics,domesticmedical underinsured residents,weekly or biweekly outreach provides monthly or small-scale outreach events offering one quarterly healthcare services,including service type,or mobile clinic visits,were also medical consultations,dental and vision arranged to provide further follow-up care. care,acupuncture,nutrition consultation, Setting up outreach isnt an easy task and health education. In 2019,a total of 313 and requires a great deal of team effort domestic medical outreach events were and organization.The domestic medical organized nationwide for local residents outreach programs Standard Operating to obtain much-needed treatments and Procedure(SOP),introduced at the 2015 free medication for those who cant afford TIMA USA Convention held in San Dimas, them.This outreach was successful due to California,was instrumental in creating the support of local partners,2,028 medical seamless workflow and assuring hygienic professionals,and 5,044general volunteers. treatment of the environment We salute 161 T=u Chi Medical Annual Report 2019 �. . ti. ,.i !1 VA q our healthcare practitioner volunteers, general volunteers,and colleagues for their tremendous effort.They planned, 7 packed and moved all the necessary Q� equipment to outreach sites the day before,and they got up at dawn to drive - two or three hours to outreach sites and set up the start of a day of care for the homeless or underprivileged communities.It is thanks to them that G this healthcare outreach for those in need,offered regardless of race,religion, gender,or age,was possible. A With volunteers'su pport,health workshops are also held at medical outreaches. huchimedical.m 17 Love and Compassion Are a Universal Language At a medical outreach event in Milpitas,California,one patient / \spoke only Minnan,a dialect �t native to parts of southern and eastern China,including most of Taiwan.Dr. David Chuang,who was volunteering his services that day and has limited proficiency in Minnan,took this patient under his wing and provided the medical care she needed. Despite not being Fluent A Tzu Chi Medical Foundation volunteer Dr. in the dialect she spoke,the doctor was David Chuang sees a patient at a Milpitas, still able to communicate with this aid CA,medical outreach. recipient,creating a sense of universal love and understanding between them, Y The medical team ata San Bernardino, which was comforting to her. CA,outreach pose for a group photo. >At a medical outreach in San Bernardino, CA Physician's Assistant Tung Ping Chiming examines a patient. A F J l7� l r t )r It � 13 1 �I lift 18 I T=u Chi Medical Annual Report 2019 Our Dental Outreach Makes Toothaches 1,755 Patient visits(Medical) Go Away reddy was very gratefu Ito be 3,725 Patient Visits(Vision) at a medical outreach event at the Salvation Army in Las Vegas, FYv 4,187 Patient Visits(Dental)where Tzu Chi Medical Foundation was W providing services.He told us that he'd VII' been coming to receive health care at 2,202 Patient Visits(Acupuncture) such events for four years out of sheer necessity."No insurance,and couldn't 2,028 Medical Professionals afford it;he explained. He had an unbearable toothache when 5,044 Volunteers he came to the outreach event this time, seeking treatment.After taking an X-ray, Dr.Phan Nguyen extracted a tooth,and as a result of this dental care,thankfully, he was able to relieve Freddy's tooth pain that very day. r r �Y— > In Las Vegas,Dr.Phan Nguyen examines a homeless patient in need of denture repair. t:umimaamatus 1 19 aJ if HEALTHY4 COMMUNI Y PROGRAMS The Healthy Community Programs The design of the programs is holistic, focus on preventive health care and to guard the body,mind,and spirit.The wel lness, and aim to improve the Healthy Community Programs also overall health of local residents through integratethe powerof communitiesand health education;the promotion of peers through the continuous support and plant-based diets,physical exercise,and partnership of City of Hope, UCLA Center a healthy lifestyle;and patientsupport for East-West Medicine,and the American groups.The programs placeprimary Cancer Society.These collaborations emphasis on serving the underprivileged, enhanced the expansion of Health as well as people with language or cultural Education workshops,the Healthy Living barriers: For instance,new immigrants or Program,and Cancer Awareness Program. members of communities in which many They also gave birth to a partnership with can't fully understand English,and the UCLA,formalized in 2019,regarding disadvantaged in general. Integrative East-West Medicine. 20 1 Tzu Chi Medical Annual Report 2019 Health Education Workshops The Health Education Program covers subjects such as Chronic Diseases, y^• Osteoporosis,Myocardial Infarction, Mental Health, Respiratory Diseases,Menopausal Syndrome, Eye Diseases,Arthritis, Medication, Dental Care,and more,aiming to support communities through the promotion of wellness and prevention.The variety of topics and reputable and renowned speakers have led to many participants becoming regulars.These Dr.Peter Chen,a board workshops have equally provided an alternative certified surgeon and Gl social gathering point for participants,where they can expand their networks and learn about healthy advocate for Cancer living together.With some community residents prevention,designed and unable to attend onsite lectures,online sessions provided a series of Cancei were launched in April 2019,broadcasting on the Awareness Workshops to radio,social media,and YouTube. the community sin 0 r t , � Tzu Chi Medical Foundation volunteers kick off a health education workshop with cheer. Uz himMlcal.us 1 21 O O 1 � Participants ask questions at a health education workshop. i Tzu Chi Medical Foundation's workshops provide valuable information relevant to the communities they serve. Cancer Awareness Program 019 was a year of recognition for the Cancer Awareness Program.Given the •a demonstrated results of pre-and post- _ test surveys of participants in cancer awareness workshops,the program won a grant from the City of Hopes"Healthy Living Grant Program" Awareness-building,prevention,and early detection through cancer awareness workshops, free colon cancer screenings, and prostate cancer screening via prostate-specific antigen(PSA) tests have benefited not only 694local residents but also their families by reducing their stress. Among the participants,87%showed that they _ learned useful cancer prevention information through a cancer awareness workshop.And 76% of attendees also demonstrated positive changes, including healthier behavior and new motivation. 221 Tzu Chi Medical Annual Report 2019 Integrative East-West The center will train healthcare Medicine distribute and volunteers to distribute self-care knowledge and tools providing holistic and integrated to local communities.Furthermore, healthcare services is in the Tzu riding on the UCLA CEWM's experience Chi Medical Foundation's DNA. and model,the services will include This quality resulted in the start of a East-West Oral Health,Eye Health, partnership in 2017 with the UCLA Mental Health,and Nutrition Programs. Center for East-West Medicine(CEWM), Ultimately,the partnership hopes to which has over 25 years of experience in improve a person's health,well-being, the field and has built a thriving health and quality of life in a safe,effective, model,benefiting tens of thousands of affordable,and accessible manner. patients.The partnership flourished and The support of the Panda Charitable was formalized in 2019,and with staunch Foundation was instrumental in the support from the Panda Charitable plan to establish the Teaching Resource Foundation, aims to build a Teaching Center. Looking ahead,we hope more Resource Center bringing together the supporters will join hands to create best principles of Western and Chinese and sustain this center,and together, Medicine in the San Gabriel Valley. accelerate a positive transformation of the healthcare system. 122 Total Health Education Program Workshops 40 Health Fairs/First Aid Stations/ Booth Exhibitions 162 Total Activities 6,331 Total Service Counts tzuchimedical.us 1 23 INTERNATIONAL ® MEDICAL MISSIONS + r .,n d 0 1 ► YY 1 'M I I 1 jZ�pl ppUt > Apatient reads upon Tzu Ch7s humanitarian and medical aid ♦ " ` `'`� around the world. 24 [.-a Chi Medical Annual Relwrt 2019 ii 1 j Working closely with Tzu Chi International Medical Association (TIMA),Tzu Chi Medical Foundation has been providing much-needed medical care to people affected by natural disasters in Central and South America. All together,we undertook five international medical missions in 2019;two to Ecuador and three to Mexico. Through them,Tzu Chi Medical Foundation kept its promise to assist communities in need by providing medical care,and helping foster local medical talent. The torch passes on: From medical professionals in the United States,Canada,Taiwan,and other nations to those in Mexico and Ecuador;from one generation to the / next;and most importantly,from patient to patient. Besides providing direct relief during international medical missions,Tzu Chi Medical Foundation has also 6 helped build TIMA chapters by providing guidance and support to local leadership and medical professionals. To carry out the work of planting seeds of collaboration and care,Tzu Chi Medical Foundation deployed a separate team to focus on training local volunteers and healthcare practitioners.The team taught Health Education, Logistics, Pain Treatment,and Team-Building Skills,subjects that will help ensure the safety and effectiveness of care. s �I Through Tzu Chi Medical Foundation's r' international missions, a total of 15,877 patients a , were consulted and treated in 2019. 1 Y A Sign language performance is always held at TI MA events to lift the spirits of both patients and volunteers. tznchimedical.us 1 25 Blue Angels Safeguarding Health On account of Tzu Chi volunteers'blue Y Dr.Willie Chen performs a treatment and white uniforms,during disaster on a patient who has suffered from an relief and medical outreach missions, eye disease for a long time. aid recipients often call them"blue angels" out of gratitude for the desperately needed help that they're getting. If we look behind - the scenes,the volunteers certainly strive to answer the call of the suffering,bringing relief through heartfelt service. On a typical day at the vision care clinic '• during one of the most recent medical j• outreach missions to Mexico in August 2019, the healthcare volunteers would attend to more than 40 patients. Dr.Willie Chen was one of the doctors volunteering his services, ;- and while there were many patients to see, he still performed detailed examinations. ? Also,he gave careful instructions on how to use medications, knowing how rare this treatment opportunity was for the people who came seeking care. He once performed seven surgeries on a single day. His dedication and attentiveness reflect the care all Tzu Chi volunteers strive to provide. As for Dr.Chen,the selfless and loving spirit of his Tzu Chi colleagues was what la he remembered the most,moved by it. He shared those feelings by saying that their heart stood out as the most beautiful things' about the experience,and continued,"If I would use a Christian word to describe it,it's like the Holy Spirit had touched[iflf > A patient receives an acupuncture treatment from Dr.Jeng Shiang Chen. 26 1 Tzu Chi MecPcal Annual Report 2019 < TIMA volunteer doctors and nurses successfully bring a big smile to a little ` boy'sface. TIMAvolunteer Mary Keh explains Tzu Chi s medical n mission to patient awaiting treatment. > Acupuncturist, Jorden,paysthe love and care of - his patients from Seattle forward to patients in Mexico. 1�+ Patients Helping Other Patients `mm order,an acupuncturist from Seattle, During the mission, a mother brought has a female patient who is Native her four-year-old daughter to the American.When she learned that medical outreach venue,hoping that Jorden was going to Mexico for a week, an acupuncturist might treat the girl's to volunteer her services during Tzu Chi asthma.Upon seeing the needles,the little Medical Foundation's medical outreach, girl started to cry.Jorden remembered she donated money to support the mission. the Apache Tears volcanic rock he had Also,she gave Jorden a bright,semi- received as a gift and used the holy Native translucent black volcanic rock,explaining, American stone to massage the child's "Our people named it Apache Tears,which chest area.Somehow,it brought a smile to have always been sacred.They can be used the little girl's face.After the session was to clean lakes and rivers, bring peace,and over,Jorden gave the mother the stone, improve the effectiveness of treatment. explaining its source,and taught her how Please take it to Mexico to those in need:' to soothe her daughter's wheezing. tzuchimedical.us 27 Financial Report _ Assets. Current assets: Cash and cash equivalents $1,688,647 $1,258,260 Investments 600,000 - ! Grants receivable 305,938- 414,896 i i Prepaid expenses 208,456 294,326 Total current assets 2,803,041 . 1967,482. Property and equipment: Transportation equipment 1,637,394 1,455,904 Computers and printers 47,525 194,688 Furniture and fixtures 5,673 33,742 Office equipment 89,029 143,310. Leasehold improvements 4,199,595. 4,181,495 Medical equipment 570,855 814,408 6,550,071 6,823,547 Less:accumulated,depreciation (2,174,022) (2,783,368) Property and equipment,net '4,376,049 4,040,179 a Other assets: j Security deposits 2,600 2,600 28 I Tzu Chi Medical Annual Report 2019 Financial Report - Liabilities & Net Assets Liabilities & Net Assets t Current liabilities: Accounts payable $83,881 $104,705 Accrued liabilities and other payables 48,661 48,918 Current obligations under capital leases 3,455 8,074 Total current liabilities 135,997 161,697 Obligations under capital leases: - 5,057 Total liabilities 135,997 166,754 Commitments and contingencies: - Net assets: Net assets without donor restrictions 5,709,129 5,843,507 Net assets with donor restrictions 1,336,564 - Total net assets 7,045,693 5,843,507 TOTAL LIABILITIES AND N ET ASSETS $7,181,690 $6.010,261 �umn�meomalus 29 Financial Report - Statement of Activities Support and Revenue Restrictions Restrictions 2019 2018 Contributions $315,372 $ - $315,372 $373,392 Grants 942.347 1.892.170 2.834.517 1.558.034 Contributed service 375,806 - 375,805 192.224 Patient service revenue 1,889,779 - 1,889,779 1,787,728 Interest and other 176,264 - 176,264 37,268 Direct public support 6BZ576 - 682.576 255.422 Netassets releasedfrom restrictions 555,606 (555,606) - - Total support and revenue 4,937,750 1,336,564 6,274,313 4,204A68 Expenses: Program services 4.124.848 - 4,124,848 3.435,963 Supportservices 947,279 - 947,279 639,116 Tatalexpenses 5,072,127 - 5,072,127 4,075,079 Change in net assets (134,377) 1,336,564 1,202,186 128,989 Net assets,beginningotyear 5,843,507 - 5,843,507 5,714,518 NETASSETS,ENDOFYEAR $5,709.130 $1,336,564 $7,045,693 $5,843,507 30 1 Tzu Chi Metllcal Anmal Repnrt2019 Sources / Use of Funds 11%Direct 5%Contributions Source of Funding publicsuppart 3%Interest and other ■ Contributions:$315,372 ■ Grants:$2,834,517 ■ Contributed service:$375,805 ■ Patient service revenue:$1,889,77? ■ Interest and other:$176,264 ■ Direct public support;$682,576 TOTAL:$6,274,313 30%Patient servicerereno 6%Contributed 45%Grants service 30%Alhambra 19%Support Use of Funding Services ■ Alhambra:$1,529,091 - ■ South El Monte:$809,005 ■ Wilmington:$545,193 ■ Mobile Free Clinics:$1,241,559 ■ Support Services:$947,279 TOTAL: $5,072,127 24%Mobile Free Urns 11%Wilmingtan 16%South El Monte UuchimedEcaLus 31 Board of Trustees Han Kuei Huang, PhD Paulina Luan Chairman Board Member Frank Su Raul Villegas Secretary Board Member Linda Sun,CPA Rosa Argentina Macias Treasurer Board Member Chin Lon Lin, MD Shin Cung Chen, LAc Board Member Board Member Joe Huang Tim Chang, Esq Board Member Board Member Martin Kuo Board Member Foundation Personnel William Keh, MD Chief Executive Officer Stephen Denq,MD Chief Medical Officer-Health Centers John Pazirandeh Chief Financial Officer Steven Voon Executive Vice President Mobile Clinics& Outreach Corinne Chau Executive Vice President-Administration& HR Jeng Shiang Chen, LAC Vice President-Acupuncture Services Peter F.Chen,MD Vice President-Healthy Community Programs Lawrence Lai, DDS Clinic Director-Dental Mobile Clinic Lina Lin,OD Clinic Director- Vision Mobile Clinic Albert Huang Clinic Director-Health Centers Thank You to Our Donors $5000-$90999 Lucy Hsu Albert Brothers Inc. Madera First 5 Alethea T. Hsu Madera Unified School District Alice Wang Maria Bella Ramir Angeles College Martin Kuo Annie Chen Matthew&Joy Lin Aurora Jose Wong MN &AC Management Inc. Brigitte Lo Network for Good Chang Ying Chen Peter FM Chen Cedric T.Chou Raymond Chau Cindy Wu Roy K. Han Wang Charles P. Koh Ryan Chau Cynthia Y. Huang Shee Hing Chow Lam Fidelity Charitable Shirley Chen Gail Wang Stacy A.Yana Yan Herbert H. Lee Sue-May Lin Kai Jendju Lu Sun's Global Trading Inc. Jiali Yan The Community Foundation John.S.Teanio The Shu Yuan Yang Living Trust Joyce Tsu Yu Chang Tingyi Wang Kaiser Permanente Foundation- Tom G.Wong Balwin Park Tung Ping Cheung Liang Inc. 34 1 T7U Ch'l MedlCai Annu21 eevmezot9 Vanguard Charitable John Hung Foundation Victor W.Jieh John P.Simmons Warrant Auditor's Kaiser Permanente Fresno Wei Chen Prive Offices Emily Chian Wei Richard K Chang Xueyun Chen Huang Silicon Valley Community Foundation Yi Son Services Inc. Valley Children Hospital Yuchen Lin William C.& Mary S. Keh $50,000-$99,999 $100,000-$500,000 American Plus Bank Panda Charitable Foundation Audiey Kao Pong Fei Chen& Kuei-Yun Yang Calviva Health S&L Huang Charitable Foundation Chenco Holding Company The California Wellness Foundation Condor Outdoor Product Delta Dental Community Fund >500,000 Fansler Foundation Kaiser Permanente Fresno Fresno County Superintendent of Schools Fresno Unified School District Good Hope Foundation Greenfast Technology Hua Lung Chang Lin tmchimMrcal.us 35 Thank You to Our Partner Agencies Health&Social Service Organizations: Herald Christian Health Center AARP Holy Family Church,Modesto ABBA Optical,Inc. Holy Name of Mary Church Alzheimer's Association Hope For Home Service Center Alzheimer's Los Angeles I Heart Wilmington American Cancer Society iPrepare Wilmington Arroyo Vista Family Health Center Kaiser Permanente,Baldwin Park Asian American Drug Abuse Program Kaiser Permanente,Fresno Behavioral Health Services Lions Club Boggs Tract Community Center,Stockton Los Angeles/Long Beach Harbor Labor Coalition Burmese Progressive Buddhist Association Madera First Five Cal Wellness Foundation Martin Luther King Jr.Community Hospital California Health Collaborative Martin Luther King Jr.Outpatient Hospital Calviva Health Martin Luther King Recuperative Care Center Care Harbor Men Educating Men About Health(MEMAH) Central City Community Health Center Molina Healthcare/Molina Medical Chapcare Monrovia Area Partnership(MAP) Chinatown Service Center Our Lady of the Assumption Church,Caruthers Chinese American Coalition for Pacific Clinic,Monrovia Compassionate Care Pacific Clinic,Pasadena City of Hope Pacific Clinic,Santa Fe Springs City of Hope,CCARE Providence Little Company of Mary Medical Downtown Women's Center Center East San Gabriel Valley Coalition for the Reading and Beyond Homeless Red Cross East Valley Community Health Center Providence Little Company of Mary Wellness El Monte Community Center and Activity Center,Wilmington El Proyecto Del Barrio Saint Agnes Medical Center Eye-Q Vision Care Saint Jude Catholic Church,Easton Fansler Foundation SBCC Thrive First Southern Baptist Church,Chowchilla Society of St.Vincent de Paul Los Angeles Flying Doctors St.Dorothy's Catholic Church Fresno County Cradle to Career St.Elizabeth Ann Satan Catholic Church Garfield Health Center St.John Vianney Catholic Church Gary Bess Associates Sun Clinical Laboratories Glenkirk Presbyterian Church Thai Temple(La Puente, Riverside,Long Beach) Happy 50 Plus The Children's Movement Fresno Harbor Community Clinic The Men's Cancer Network,Inc. 36 1 Tzu Chi Medical Annual Report 2019 UCLA Center for East-West Medicine Clovis Unified School District Valley Children's Healthcare East Los Angeles College Vietnamese Temple Evans Community Adult School WARP organization Fedde Middle School Westly Foundation Firebaugh Las Deltas School District Wilmington Chamber of Commerce Fowler Unified School District YWCA Greater Los Angeles Fresno Community College Zero-The End of Prostate Cancer Fresno County Superintendent of Schools Fresno Unified School District Government Agencies: Golden Plains Unified School District Census 2020 Highlands Community Charter School, City of Los Angeles Emergency Management Sacramento Department Loma Linda University City of Monrovia Madera Unified School District City of Rosemead Mendota Unified School District City of San Gabriel Mt.San Antonio College Student Health Center Department of Mental Health-LA County North-West College Fresno County Health Department Services Orange Center Unified School District LAPD Harbor Division Parlier Unified School District Los Angeles City Council 15th District Pasadena City College Los Angeles County Department of Mental Riverdale Joint Unified School District Health San Joaquin Valley College,Fresno Los Angeles County District 1 Supervisor Sanger Unified School District Hilda L.Solis Tzu Chi Education Foundation Los Angeles County District 2 Supervisor Tzu Chi Great Love Elementary School, Mark Ridley-Thomas Monrovia Los Angeles County Fire Department Tzu Chi Great Love Preschool,Walnut San Bernardino County HICAP University of Southern California School of Social Work Eduwtional Institutions: Washington Unified School District ABC Unified School District West Park School District Alhambra Civic Center Library Western University Alvina Elementary Charter School District Aspen Charter School Burrel Union Elementary School District California State University,Fresno California State University,Fullerton Central Unified School District tz.icl,,memcalus 37 9 'r4th� ?,• rr a � e :Y Buddhist Tiu Chi Medical Foundation ilJII]ES'TAR Alhambra,CA 91801 ' Tel:626-427-9598 Fax: 626-788-2321 Buddhist Tzu Chi Medical Foundation is a tzuchimedical.us GuideStar Platinum Participant Tzu Chi Supplementary Information For Cupertino Community Grant Application 2021 Tzu Chi has been a community partner with West Valley Community Services (WVCS) since 2007. Every Friday, regardless of shine or rain, Tzu Chi volunteers collected donated produce at the Cupertino Farmers Market for WVCS's food pantry program benefiting low-income families in the community. WVCS has nominated Tzu Chi for various awards in the last 13 years. In 2010, Tzu Chi was awarded the Asian American Hero Award in Santa Clara County In 2015, Tzu Chi was awarded with the Crest Award by City of Cupertino Attached with a short video produced by the Cupertino Crest award team in 2015: CREST 2015: Tzu Chi www.youtube.com/watch?v=16eOt2kSc4s&t=2s Tzu Chi is an international humanitarian organization and a non-governmental organization with an international network of volunteers. In Cupertino, the Tzu Chi members meet the West Valley Community Services van at the local Farmer's Market and immediately begin dropping off crates to all the Farmers that have saved produce for WVCS. In 2014, they collected 40,000 pounds of produce. Not only they formed relationships with WVCS, but they also formed relationships with the local growers and businesses in the area. Tzu Chi has many initiatives, including dental medical services. Tzu Chi Mobile Clinic Milpitas provides free dental care to low-income families and has reached out to many Bay Area families. For example, we were awarded the Facebook Community Fund and SMILE Grant in 2019, and collaborated with Ravenswood School District in East Palo Alto, Children Health Council and the Boys and Girls Club of the peninsula to provide two free dental outreach events to serve over 120 residents in East Palo Alto. Here are some information about our 2019 East Palo Alto dental outreach events. Attached are two videos produced by Tzu Chi. These are related to Tzu Chi free medical outreach events: [English] A Fulfilling Mission: Tzu Chi Volunteers Provide Low-Income Immigrant Communities With Free Dental Care: https://tzuchimedical.us/blop-/tzu-chi-volunteers-provide-low-income-i mmigrant- communities-with-free-dental-care [Chinese] AMWkV #J�ZftFK -r*: httQs://tmchi.us/zh/blog/nea-east-pato-alto-dental-outreach-201912 While working with WVCS, we also noticed that some local low-income families may benefit from our free dental services. We hope to be awarded with the Cupertino Community Chant to offer Cupertino low-income residents more with free dental care and medical services. Bhuddhist Tzu Chi Medical Foundation (New) Eligibility Checklist (staff use only) Eligibility YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/project/event Identify how the funds will be used to benefit the Cupertino x cormnunity Be awarded only once per.project X For specific needs,not on going,operational costs X Have more than 75%of the requested funds allocated for direct service costs versus'administrative costs X Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shag only NA submit one application 12e.Proceeds generated from the funded activity may only be used for the conducted activity NA admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved NA by Parks and Recreation Commission City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever feceived a City of Cupertino Community Funding Grant in the past? Q Yes * No If. Yes, when? ?,i ` : CONTACT INFORMATION Legal Name of Organization:Dhwani Academy of Percussion Music ill the United States Web Address: Oor :11 demyms Mailing Address: City: ona Zip. 92882 Phone PresidenVE=xecutive Director:Apratim Sanerjee Title: Execut ve erector Email: dhwaniacademy@yahoo,com Telephone Number Contact Person: Kiran Kulkarni Title: olunteer Email Address: dhwaniacademya@yahoo.com Telephone Number: 541{c}(8)? * Yes Q No Year Established 2004 Federal Tax ID3� Fiscal Sponsor Name: Dhwani Academy of Percussion Music in the United States Fiscal Sponsor Address: City: Corona Zip: 92882 Phone. :ECTION 3: ORGANIZATION INFORMATIOi-. Total Organization Budget: $152,000 Total # of Board Members: 5 Total #of staff: a Total # of Volunteers: 18 Mission Statement: Promote Indian classical &traditional music among Indian Diaspora &expand awareness in other communities. Create center where different traditional music along with Indian musical Traditions will be nurtured & experimented via learning opportunities provided to students through traditional GURUKUL system, performances with stalwart musicians, residencies, seminars,workshops & festivals. Researches on old scriptures, recordings, traditional styles are to be taken into consideration &will be documented. Making experiments with other traditional music without losing purity and make them available online physical for interested music lovers and also For public awareness. Brief Description of Organization: Dhwani Academy was founded in Southern California in 2004 by Abhijit Banerjee,a leading Indian musician and his music loving friends with the aim of researching and promoting traditional music of India with special emphasis on Indian classical and folk percussion and to experiment and collaborate them with other kinds of traditional music of the world. It has been doing promotional activities of traditional Indian percussion and music by teaching many students. exposing therm to the community and making collaborative works with other traditional music such as Japanese Taiko, music from South America and Indonesian traditional music, Since its inception the academy has taught numerous students, some of whom are already performing in local and international events. The academy holds regular events like residencies, workshops and music festivals to promote and collaborate culture and give the music students a platform to expose themselves in front of music loving audience Brief Description of Services Provided: The Academy teaches Tabla, folk Percussion and South Indian Rhythm in Southern and Northern California. The academy has organized many outreach programs with Whittier College, La Jolla Country Day School, Conducted community events like Musical Institute Museum, Phoenix Library, World Drum Festival, Earth Day, Pasadena Music Conservatory, Ektaa Fest, Music Circle of Los Angeles, Soka University Community day. The academy organizes regular workshops in Irvine and Cupertino with established professional artists from India and the US, opened its satellite classes in New York and Phoenix, hosts concerts with artists like Grammy Winner Vishwa Mohan Bhatt and many others and also crossed community barriers by collaborating with artists from other genres like Kenny Endo (Taiko), Dewa Barata (Indonesian Drummer, Shekar Jaya of San Francisco), Paul Livingstone (Sitar and Guitar player). Each event is represented by talented students to promote them& share stage with established ar SECTION 4: GRANT REQUESTS 1.Program/ProjeWEvent Name: RAGA AND RHYTHM 2.Date(s)andlor duration of program/projeGVevent(if applicable):stading 06/01/2021 duration? months 3.Total program/projec(event budget: $18,150 4.Requested Amount: $9.100 Percent of total program/projectievent budget: 50% 5.Program/Project projected income: $3,750 Percentage of your organization's projected income:21% 6.Type of Request: OCapital Improvement 8 Program Support ❑Event 0One-time project DOther: Support workshops, Evaluation of students and music wncert far community. 7.This grant will fund a(n): 12 Existing prograrrdprajectlevent;established in 2016(year) 0 New program/pmjecUevent 8. Describe the purpose of requested funds and the services that will be provided: The academy courteously appeals financial support to conduct leaning of music&percussion art fors of India, Series of Workshops, Evaluation Concerts ending with a Music Festival in Cupertino. The academy will do around two workshops(1-2 days/each)&interactive sessions for the benefit of the students& wishes to invite Traditional Musicians& Percussionists to instruct the ad form which are seldom practiced outside India. Classes will be done in Gumkul system.There will be long practice sessions &the students on the workshops days spend time on listening music, practicing- kind of intensive with a more personal touch. Evaluation based Concert will be conducted at the end of workshops by inviting visiting artists featuring good students to perform.This will give experience,exposure &encouragement to the students&will also encourage the community to be involved in good music.This year we will take help of online presentations of talented students and invited a 9. Please provide a line item breakdown of how the funds will be used in the categories below. 9 a category is not aoplicable, put$0: Admin Staff $75 Materials/E ui ment $200 Entertainment $250 Room/Venue Rental $1,900 Other Professional Services Artist fees for recital concert$2000( artists @$1000), Evaluation concert$1500 (two artists @750 $p 750 ach)) , two artists workshops$2000(two adists 2 workshops @ 00 each for 4 days) Other Car rent(@75 Including Gas x 20 days,Artist lodging 700/dayx20 days, Per diem @501dayx20, Documentation and $3.25C nline facility$2000 otal [$9,1001 10.Explain how the request aligns to City mission and values: The city of Cupertino has quite a siuble amount of Indian community and some are residing with 2nd and 3rd generations. Regular influx of professionals from different countries including India for different reasons creates the need of nurturing of good cultural activities that helps to build a healthy community.. Our activities with Indian music and teaching of traditional art for will make the community culturally strong and healthy.The kids from Indian background will gel to know their origin.The community people will get involved in healthy cultural activities involving their mot.The cross over activities and collaborations with other traditional music and culture will get different communities under one roof and inter mingling of cultures gives each community a broader out look and hor¢on. 11.Describe how the program/projeGVevent fills a community need.Who identified this need?What other similar project/program/event exists to serve Cupertino residents?How is your proposed projact/prograMevent unique from similar projects/programslevents or how do you collaborate to avoid duplication? Cupertino Indian community is in need of apt artistic society to build up a cultured mental development and to know their roots . The volunteers based in Cupertino and their families identified the need of activities to keep them and their kids rooted to their culture and mingling with other cultures actively. Dhwani Academy serves the community with such diverse and cross cultural activities so far as the artistes involved. The uniqueness of Dhwani is to involve really established artistes to participate, perform and doing workshop with Kids to make them educated with their expertise.Collaborative works emphasizing Rhythmical part of music and how to interact and accompany different kind of music is the essence of our work. 12.Who will be served by this grant? Persons residing in Cupertino and nearby area fascinated in traditional Music will be benefited.This project is directed to cater all the music lovers especially with South Asian and Indian background. Our target participants are the interested kids and youth.we try to expose them towards traditional music of India. Our target audience to be served is the Indian community people and communities beyond that with cross cultural interest. a)Number of individuals total: 22 b)Number of Cupertino residents: 16 c)Particular community groups: Indian, South Asian communities ( Bangladesh , Pakistan,Singapore, Malaysia), Ethnic groups are to be benefited. d)Will the program/proj"Vevent be available to the entire community/public or are there any eligibility criteria? The project will be available to anybody interested in the community for participation. However it will be organized into groups.Active participation with Instruments will have beginners and advanced level.Advanced level workshops need a basic knowledge, Our workshops and evaluation concerts are open for all the community to join and watch. e)Will there be a charge or fee for the program/project/event(If applicable) It will be free for the Cupertino residents to attend the workshops. It might have some charges for active participation with instruments.The evaluation concert will be free of charge mainly for the Cupertino residents.The culminating music festival will have donation tickets to attend which is mainly for non-cupertino residents.The Cupertino residents will pay only 25%of the ticket value. f)What outreach methods does your organization use to promote the programlproject/evenl(if applicable)? We will use social media such as Facabook,You tube, Instagram to promote our events. For major festivals and evaluation concerts we will use paper and a-advertisements through established publications and leaflets to be kept in different public places for promotion. 13. Describe how the funds will be used to benefit or impact the Cupertino community: Students& musicians are the beneficiaries of these Workshops and music concerts. Level of learning &upbeat communication among maestros& students are deemed to be the expected benefit. With a vow for artistic uniqueness, mast of 1st and 2nd generation Indian offspring are Introduced to Indian music as a preamble to their culture.Non-Indian &western students developed an interest in Indian music through association of other activities. In either case,the academy's role is to develop the student's education in Indian traditional music&its relation to world music. Music lovers fascinated in Indian heritage, 3rd generation Indian origin kids of Cupertino, musicians nurturing Indian traditional art form&crossover music are benefited from concerts. Existing Indian musicians learn from workshops provided by invited Maestros from India. Non Indian&western musicians spend time to gain a better understanding of musiclto utilize musical base for fusion experiments&performances 14. Demonstrate that the member implementing and managing the program/project/event have adequate experience: Dhwani Academy has been doing activities like workshops, music festivals involving communities for last 14 years in southern California and for last four years in Cupertino. We have experienced volunteer from Cupertino who has been handling such events for last four years very successfully.Our Volunteer Kiran Kulkami, Ibhanan, Samit, Salyen are quite equipped to handle all the needs such as arranging instruments, inviting guests, handling stage and needs of the artistes. In the workshops we have volunteers to make arrangements for participants for their instruments, refreshments. Our media team will handle the documentation for archive. more over the artistic director of Dhwam Abhijit Banerjee is a vastly experienced person to make curate and make our projects most productive to the participants. 15.How will success of the programlprojectlevent be measured?: A core team of 4 involving Artistic Director, Cultural Activist&Community Representative with extended members will evaluate the plan &will measure the outcome of the project. Students' note on workshops&their performances in concerts, audience review after concerts, explanatory sessions will be the yardstick of measurement. 1.A favorable outcome will be if a majority of residency participants say YES for their involvement next time 2.A favorable outcome will be If a majority of audience says YES whether they learn something new while trying a traditional an or skill that they experienced &will they wants more or will they like to learn any of these or recommend anybody. 3.Whether enough materials are collected(Audio,Video& photographs)during residency that can be published. 4.Audience demographics to assess our reach that reflects the local&regional demographics In terms of age, gender, race&income. 16.Will more than 75% of the requested funds go towards direct service costs versus administrative costs? O Yes O No 17.Will you collaborate with other organizations to deliver the programlproject/event funded by this grant? If so, which organizations? NO. 18. If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants,please describe this support: NO. 19.Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of program/projectievent(e.g.fee waivers)? If so, please describe this anticipated support: NO. 20. If you are a multiJimisdiclional organization,describe any funding requested from other agencies/organizations in regards to this program/project/event request. Indicate whether the funding was granted, denied, or is still pending: We got funding for similar projects for last four years from National Endowment for Ads.We used a portion of that in Cupertino for making our project successful.This year we have applied for funding from the same agency which is still pending. 21.How would you fund the program/project/event If you do not receive the requested funding?: We will fund it from our existing resources and the magnitude will have to be cut down.We will however continue our workshops and evaluation concert along with the culminating musical event from collecting private donations and sponsorships from the interested people wants to help to continue and from the funding from NEA if we get It as we did in the past.The festival will be conducted on the bass of tickets, private donations and sponsorships and funding from NEA if we get it. SECTION 5: PRIOR FUNDING 1. If you received a Community Funding Grant in prior years, indicate the amounts for each year and describe how those funds were used: No 2. If you received a Community Funding Grant last year: a.Please provide a line item breakdown of how the Community Funding Grant was used last year in the categories below. If a category is nut applicable, put$0: Idmin Staff $ Materials/E ui ment $ Entertainment $RoomNenue Rental $Other Professional Services $Other $tal $ b.Who was served by the grant last year? N/A I. Number of individuals total: 0 ii. Number of Cupertino residents:NA ill.Particular community groups N/A Iv.Was the program/project/event available to the entire community/public or are there any eligibility cntena7 N/A v.Was there a charge or fee for the program/project/event(if applicable)? N/A vi.What outreach methods did your organization use to promote the progmm/project/evenl(if applicable)? N/A c.Was the program/projectlevent successful? Please indicate haw success was measured: NIA 3. Please Indicate any additional funding received last year from other sources and provide your financial statement if available: N/A Attachments: Attach your financial statment,and any other helpful information about your project. works op 2019.JPG DHWANIACADEMYOFEEBQUSSIONMU51C 2019 tazpdf Program Manager Signature Executive Director Date Signed M0112021 Form 8879-EO IRS a-file Signature Authorization for an Exempt Organization OMB No.1545-1878 Forcalendaryear2019,orfiscal year beginning __-_____ .2019,andending 20 ^O� Department of the Treasury Do, Do not send to the IRS.Keep for your records. Internal Revenue service ► Go to www.frs. ov/Form8879E0 for the latest information. "[jj) Name of exempt organization Employer ldentificallon number DHWANI ACADEMY OF PERCUSSION MUSIC 77 _ _ Name and title afofficer ABHIJIT BANERJEE 11/14/2018 VFW _Type of Return and Return Information(Whole Dollars Only) Check the box for the return for which you are using this Form 8879-EO and enter the applicable amount,If any,from the return. If you check the box on line Ia,2a,3a,4a,or 5a,below,and the amount on that line for the return being filed with this form was blank,then leave line 1b,2b,3b,4b,or 5b,whichever Is applicable,blank(do not enter-a-).But,if you entered -0-on the return,then enter-0-on the applicable line below.Do not complete more than one line in Part I. is Form 990 check here ►❑ b Total revenue,if any(Form 990,Part VIII,column(A),line 12). 1b 2a Form 990-EZ check here ► ❑X b Total revenue,If.any(Form 990-EZ,line 9). . . . . . . . . . 2b 152,316 j 3a Form 1120-POL check here ► ❑ b Total tax(Form 1120-POI,line 22). . . . . . . . . . . . 3b 4a Form 990-PF check here ► ❑ b Tax based on investment income(Form 990-PF,Part VI,line 5) 4b 5a Form 8868 check here ►❑ b Balance Due(Form 8868,line 3c). . . . . . . . . . . . . 5b 3 Declaration and Signature Authorization of Officer _ Under penalties of perjury,I declare that I am an officer of the above organization and that I have examined a copy of the organization's 2019 electronic return and accompanying schedules and statements and to the best of my knowledge and belief,they are true,correct,and complete.I further declare that the amount in Part I above Is the amount shown on the copy of the organization's electronic return.I consent to allow my intermediate service provider,transmitter,or electronic return originator(ERO) to send the organization's return to the IRS and to receive from the IRS(a)an acknowledgement of receipt or reason for rejection of the transmission,(b)the reason for any delay In processing the return or refund,and(c)the date of any refund.If applicable,I authorize the U.S.Treasury and its designated Financial Agent to initiate an electronic funds withdrawal(direct debit)entry to the. financial Institution account indicated in the tax preparation software for payment of the organization's federal taxes owed on this return,and the financial institution to debit the entry to this account.To revoke a payment,I must contact the U.S.Treasury Financial Agent at 1-888-353-4537 no later than 2 business days prior to the payment(settlement)data.I also authorize the financial institutions involved in the processing or the electronic payment of taxes to receive confidenllal Information necessary to answer Inquiries and resolve Issues related to the payment.I have selocted a personal identification number(PIN)as my signature for the organization's electronic return and,if applicable,the organization's consent to electronic funds withdrawal, Officers PIN:check one box only ❑ I authorize S 8r A ASSOCIATES CPA'S to enter my PIN as my signature ERO 8rm name Enter five num err,but do not enter all zeros on the organization's tax year 2019 electronically filed return.If I have indicated within this return that a copy of the return is being filed with a state agency(ies)regulating charities as part of the IRS red/State program,I also authorize the aforementioned ERO to enter my PIN on the return's disclosure consent screen. ❑X As an officer of the organlxation,Twill enter my PIN as my signature on the organization's tax year 2019 electronically 11 filed return.If I have indicated within this return that a copy of the return is being filed with a state agency(les)regulating charities as part of the IRS Fed/State program, I will enter my PIN on the return's disclosure consent screen. Officers signature ► Date ► 7/20/2020 Certification and Authentication ERO's EFINIPIN.Enter your six-dlgit electronic filing identification number(EFIN)followed by your five-digit self-selected PIN. do not enter all zeros I certify that the above numeric entry is my PIN,which is my signature on the 2019 electronically filed return for the organization indicated above.I confirm that I am submitting this return in accordance with the requirements of Pub.4163,Modernized 9-File (MeF)Information for Authorizzed IRS a-file Providers for.Business Returns. ERO's algnature. ► SUBHRA K BANERJEE Date ► ERO Must Retain This Form--See Instructions Do Not Submit This Form to the IRS Unless Requested To Do So For Paperwork Reduction Act Notice,see back of form. Form 8879-EO (2o19) HTA Form 8879r EO IRS e-file Signature Authorization - for an Exempt Organization For calendar year 2019.or fiscal yearbaginning _-____- .2019,andending 20 Department of the Treasury to, Do not send to the IRS.Keep for your records. �O 9 Internal Revenue Service ► Go to wwmirs. ov/Form8879E0 for the latest Information. Name of exempt organization Employer Identification number DHWANI ACADEMY OF PERCUSSION MUSIC Name and this of offlcar ABHIJIT BANERJEE 11/14/2018 Tvipa of Return and Return Information Whole Dollars Onl Check the box for the return for which you are using this Form 8879-EO and enter the applicable amount,if any,from the return. j If you check the box on line 1a,2a,3a,4a,or 5a,below,and the amount on that line for the return being filed with this {{1 form was blank,then leave line Ib,2b,3b,4b,or 5b,whichever is applicable,blank(do not enter-0-),But,If you entered -0-on the return,there enter-0-on the applicable line below.Do not complete more than one line in Part I. is Form 990 check here -►❑ b Total revenue,if any(Form 990,Part Vill,column(A),line 12). . . 1b 2a Forrfl 990-EZ check here ►.[:] b Total revenue,if any(Form 990-EZ,line 9). . . . . . . . . . 2b 3a Form 1120-POL check here ► D b Total tax(Form 1120-POL,line 22). . . . . . . . . . . . 3b 1 4a Form 990-PF check here ► 71 b Tax based on investment income(Form 990-PF,Part VI,line 5) 4b 5a Form 8868 check here,s OX b Balance Due(Form 8868;line 3c). . . . . . . . . . . . . . . 5b 0 17 Ma Declaration and Signature Authorization of Officer Under penalties of perjury,I declare that I am an officer of the above organization and that I have examined a copy of the organization's 2019 electronic return and accompanying schedules and statements and to the best of my knowledge and belief,they i are true,correct,and complete.I further declare that the amount In Part I above is the amount shown on the copy of the organization's electronic return.I consent to allow my intermediate service provider,transmitter,or electronic return originator(ERO) to send the organization's return to the IRS and to receive from the IRS(a)an acknowledgement of receipt or reason for rejection of the transmission,(b)the reason for any delay in processing the return or refund,and(c)the date of any refund.If applicable,I authorize the U.S.Treasury and its designated Financial Agent to Initlate an electronic funds withdrawal(direct debit)entry to the financial institution account indicated in the tax preparation software for payment of the organization's federal taxes owed on this return,and the financial institution to debit the entry to this account.To revoke a payment;I must contact the U.S.Treasury Financial Agent at 1-886-353-4537 no later than 2 business days prior to the payment(settlement)data.I also authorize the financial Institutions involved in the processing of the electronic payment of taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment.I have selected a personal identification number(PIN)as my signature for the organization's electronic return and,if applicable,the organization's consent to electronic funds withdrawal. Officer's PIN:check one box only I authorize S&A ASSOCIATES CPA'S to enter my PIN as my signature El firm name Enter five numbers,but do not enter all zeros on the organization's tax year 2019 electronically filed return. if I have indicated within this return that a copy of the return is being fled with a state agency(ies)regulating charities as part of the IRS Fed/State program,I also authorize the aforementioned ERO to enter my PIN on the return's disclosure consent screen. X As an officer of the organization, I will enter my PIN as my signature on the organization's tax year 2019 electronically filed return.If I have Indicated within this return that a copy of the return is being filed with a state agency(€es)regulating charities as part of the IRS Fed/State program,I will enter my PIN on the return's disclosure consent screen. Officer's signature ■ Date ■ Certification and Authentication ERO's EFINIPIN.Enter your six-diglt electronic filing identification number(EFIN)followed by your five-digit self-selected PIN. do not enter all zeros I certify that the above numeric entry is my PIN,which is my signature on the 2019 electronically filed return for the organization indicated above.I confirm that I am submitting this return in accordance with the requirements of Pub.4163,Modernized a-File (MeF)Information for Authorized IRS a-file Providers for Business Returns. ERO'saignatura ► SUBHRA K BANERJEE Date ► 7/20/2020 ERO Must Retain This Form—See Instructions Do Not Submit This Form to the IRS Unless Requested To Do So For Paperwork Reduction Act Notice,see back of form. Form 8879-IEO (2o19) HTA 1aa Date Accepted DO NOT MAIL.THIS FORM TO THE FTB TAXABLE YEAR California a-file Return Authorization for FORM 201.9 Exempt Organizations 8453-EO Exempt Organization name Identifying number DHWANI ACADEMY OF PERCUSSION MUSIC Part I Electronic Return Information{whole dollars only) 1 Total gross receipts(Form 199,line 4). .. ... ... .... .... . .. ... ... .. ... ... . .. ... .... .. ..... .... .... 1 152,316 2 Total gross income(Form 199,line 8).. .. ... .. .. . .. .. ... ... ... .... .. ... .. . .. .. ... .. ........ .... 2 152,316 Total expenses an disbursements s( o rm 199,Line 9).... .. .... .. . .. .. ... . .... ..... .... 3 _ 139,862 Part 11 Settle Your Account Electronically for Taxable Year 21119 4 �X Electronic funds withdrawal 4a Amount 10 4b Withdrawal date(mmlddlyyyy) 07/25/2020 Part Ill Banking Information(Have you verified the exempt organization's banking information? 5 Routing number 6 Account number 7 Type of account: �X Checking ❑ Savings Part IV Declaration of Officer I authorize the exempt organization's account to be settled as designated In Part II.If I check Part II,Box 4,1 authorize an electronic funds withdrawal for I the amount listed on line 4a. Under penalties of perjury,I declare that I am an officer of the above exempt organization and that the information I provided to my electronic return originator(ERO),transmitter,or intermediate service provider and the amounts in Part I above agree with the amounts on the corresponding lines of the exempt organization's 20113 California electronic return.To the best of my knowledge and belief,the exempt organization's return is true,correct,and complete.If the exempt organization is filing a balance due return,I understand that if the Franchise Tax Board(FTB)does not receive full and timely payment of the exempt organization's fee liability,the exempt organization will remain liable for the fee liability and all applicable interest and penalties. authorize the exempt organization return and accompanying schedules and statements be transmitted to the FTB by the ERO,transmitter,or intermediate service provider.If the processing of the exempt organization's return or refund is delayed,1 authorize the FTB to disclose to the ERO or Intermediate service provider the reasons)for the delay. Sign ,. I �11/14/2.018 Here Slgnabrreofonicer Date Title Part V Declaration of Electronic Return Originator(ERO)and Paid Preparer.See instructions. I declare that I have reviewed the above exempt organization's return and that the entries on form FTB 8453-EO are complete and correct to the best of my knowledge.(If I am only an Intermediate service provider,I understand that I am not responsible for reviewing the exempt organization's return. declare,however,that form FTB 8453-EO accurately reflects the data on the return.)I have obtained the organization officer's signature on form FTB 8453-EO before transmitting this return to the FTB;I have provided the organization officer with a copy of all forms and Information that I will file with the FTB,and I have followed all other requirements described In FTB Pub.1345,2019 Handbook for Authorized a-file Providers.I will keep form j FTB 8453-EO on file for four years from the due date of the return or four years from the date the exempt organization return is filed,whichever is later,and I will make a copy available to the FTB upon request.If I am also the paid preparer,under penalties of perjury,I declare that I have examined the above exempt organization's return and accompanying schedules and statements,and to the best of my knowledge and belief,they are true, correct,and complete.I make this declaration based on all information of which I have knowledge. ERO's- Dale Check if Check ERO'e PTIN ERO signature . SUBHRA K BANERJEE alsopald itself pieparar employed❑X Must Flrm's FEIN Firm's name(or yours Sign If self-employed) Zle code and address LOS ANGELES CA 190071 Under penalties of perjury,I declare that I have examined the above organization's return and accompanying schedules and statements,and to the best of my knowledge and belief,they are true,correct,and complete.I make this declaration based on all information of which I have knowledge. Paid Pald Date Check Pe Id preparer's PTIN Preparer signawrea I SUBHRA K BANERJEE _ employed© Must Flrm's FEIN Firm's name(or yours SUBHRA K BANERJEE Sign If self-employed) ZIP code and address Los ANGELES CA 190071 For Privacy Notice,get FTB 1131 ENGISP. FTB 8453-EO 2019 Short Form Form 990-EZ Return of Organization Exempt From Income Tax 1W19 Under section 501(c),527,or 4947(a)(1)of the Internal Revenue Code(except private foundations) IN, Do not enter social security numbers on this form,as it may be made public. + Dpartment of the Revenue Treasury ► Go to www.irs.9ov/Form990EZfor instructions and the latest Information. A For the 2019 calendar year,or tax ear beginning and ending B Check if applicable: C Name of organization D employer identification number ❑ Address change DHWANI ACADEMY OF PERCUSSION MUSIC ❑ Name change Number and street(or P.O.box If mall is not delivered to street address) Room/suite Initial returnIF E Telephone number Final returnRerminated City or town slats ZIP code Amended return Corona CA 92882-4741 Application pending Foreign country name Foreign provincelstateloounty Foreign postal code f Group Exemption Number► G Accounting Method: X] Cash ❑Accrual Other(specify) ► H Check-►0 'rf the organization is Website: ► NIA not required to attach Schedule B J Tax-exempt status(check only one)— �X 501(c)(3) Ej 501(c)( )/ (Insect no.)❑4947(a)(1)or ❑527 (Form 990,990-EZ,or 990-PF). K Form of organization: 0 Corporation Trust Association ElOther L Add lines 5b,6c,and 7b to line 9 to determine gross receipts.If gross receipts are$200,000 or more,or if total assets Part II,column B are$500,000 or more,file Form 990 instead of Form 990-EZ . ► $ 152,316 Revenue, Expenses,and Changes in Net Assets or Fund Balances(see the instructions for Part 1) Check if the organization used Schedule O to respond to any question in this Part I 1 Contributions,gifts,grants,and similar amounts received. . . . . . . . . 7 73,950 2 Program service revenue including government fees and contracts. . . . . . . . . . . 2 78,366 3 Membership dues and assessments. . . , . . . . . . . . . . . . . . . . . 3 4 Investment Income. . . . . . . . . . . . . . . . . . . . . . . 4 5a Gross amount from sale of assets other than inventory 5a w k b Less:cost or other basis and sales expenses. 5b c Gain or(loss)from sale of assets other than inventory(subtract line 5b from line 5a). . . . . . . 5c 0 6 Gaming and fundraising events: d a Gross income from gaming(attach Schedule G if greater than a $15,000) . . . . . . . . . . . . . . . . . 6a a b Gross Income from fundraising events(not Including $ of contributions from fundraising events reported on line 1)(attach Schedule G if the sum of such gross income and contributions exceeds$15,000). . . 6b c Less:direct expenses from gaming and fundraising events.. 6c s d Net income or(loss)from gaming and fundraising events(add lines 6a and 6b and subtract ,•., l line 6c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6d 0 7a Gross sales of inventory,less returns and allowances. . . . . . 7a $ b Less:cost of goods sold. . . . . . . . . . . . . . . . L 70 c Gross profit or(loss)from safes of inventory(subtract line 7b from line 7a). 7c 0 8 Other revenue(describe In Schedule 0). . . . . . . . . . . . . . . . . . . . . . 8 9 Total revenue.Add lines 1,2 3,4 5c 6d,7c,and'8. ► 9 152,316 10 Grants and similar amounts paid(list in Schedule 0). . . . . . . . . . . . . . . . . . . 10 11 Benefits paid to or for members. . . . . . . . . . . . . . . . . . . . . . . . 11 12 Salaries,other compensation,and employee benefits. . . . . . . . . . . . . . . . . . . 12 52,869 13 Professional fees and other payments to independent contractors . . . . . . . . . . . 13 34,144 n. 14 Occupancy,rent,utilities,and maintenance. . . . . . . . . . . . . . . . . . . . 14 15,948 15 Printing,publications,postage,and shipping . . . . . . . . . . . . . . . . . . . . . 15 232 16 Other expenses(describe in Schedule O) . . . . . . . . . . . . . . . . . . . . . . . 16 36,669 17 Total expenses.Add lines 10 through 16. , 11, 17 139,862 18 Excess or(deficit)for the year(subtract line 17 from line 9). . . . . . . . . . . . . . . 18 12,454 •19 Net assets or fund balances at beginning of year(from line 27,column(A))(must agree with �1 end-of-year figure reported on prior year's return). . . . . . . . . . . . . . . . . . . . 19 19,663 20 Other changes in net assets or fund balances(explain in Schedule O) . . . . . . . . . . . . 20 21 Net assets or fund balances at end of year.Combine lines 18 through 20 ► 21 32,117 For Paperwork Reduction Act Notice,see the separate Instructions. Form 990-EZ(201 s) in'A Form 990-EZ(2019) DHWANI ACADEMY OF PERCUSSION MUSIC pone 2 LM Balance Sheets(see the instructions for Part II) Check if the organization used Schedule 0 to respond to any question in this Part II. . . . . . . . . . . . . . . . . . . X❑ (A) Beginning of year (B) End of year 22 Cash,savings,and Investments . . . . . . . . . . . . . . . . . . . . . .. . 23.026 22 37,697 23 Land and buildings. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 24 Other assets(describe in Schedule O). . . . . . . . . . . . . . . . . . . 1,000 24 100 25 Total assets. . . . . . . . . . . . . . . . . . . . . . . 24,026 25 37,797 26 Total liabilities(describe in.Schedule O). . . . . . . . . . . . . . . . . . . . 4,363 26 5,680 27 Net assets or fund balances line 27 of column B must agree with line 21 . . . 19,663 271 32 117 Statement of Program Service Accomplishments(see the instructions for Part III) Check if the organization used Schedule O to respond to any question in this Part III. . . . . . . ❑ Expenses What is the organization's primary exempt purpose? TO PROMOTE INDIAN CLASSICAL MUSIC AND CULTURE (Required for end action (4) Describe the organization's program service accomplishments for each of its three largest program services, organizations;optional as measured by expenses.In a clear and concise manner,describe the services provided,the number of for others.) persons benefited,and other relevant information for each program title. 28 THE ORGANIZATION ORGANIZED AND PROMOTED VARIOUS CONCERTS ON INDIAN CLASSIC__A_! ---- -- j MUSIC DURING THE YEAR.THE ORGANIZATION PROVIDED LESSONS ON LEARNING INDIAN - - - --- ---- ------- -- -- --- - -- -- - - ------------- _.._---------------------- -------- PERCUSSION MUSIC -- - --- ---- -- -------------------------------------------------------------------------------------------- (Grants$ ) If this amount includes foreign grants,check here. . . . . . . ► ❑ Y8a I 29 ----------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------- i (Grants$ ) If this amount includes foreign grants,check here. . . . . . . ► ❑ 29a 30 ----------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------- (Grants$ } If this amount includes foreign grants,check here. . . . . , . ► ❑ 30, 31 Other program services(describe in Schedule 0). . . . . . . . . . . . . . . . . . . . . . . (Grants$ } If this amount includes foreign grants,check here. . . . . ► ❑ 31a 32 Total program service ex enses_ add lines 28a through.31a ► 32 0 List of Officers,Directors,Trustees,and Key Employees(list each one even if not compensated—see the instructions for Part IV) Check if the organization used Schedule O to respond to any question in this Part IV . . . . . , . . . . . . ❑ (c) Reportable (d)Health benefits, (b) Average compensation contrlbullons to (e)Estimated amount of a Name and 1 (Farms W-211099-MISC 11le haure per week ) employee benefit plans, other compensallen devoted to position (if not paid,enter-0-) and deferred compensation ABHIJIT BANERJEE PRESIDENT HrMK 4.00 BALDEV JHITA TREASURER Hr1WK 2.00 JYOTIPRAKAS MISTRI - - - ------------------------------------------------ SECRETARY HrMK 32.00 ----------------------------------------------------------- HrNVK ------ HrA'VK -------- HdWK --------------------------------------------'--------------- HrNVK ------------_..._-------------------------------------------- HAWK .----------------------------------- --- 'HAWK --- ----------------------------------------- WANK ------------------------------------------------------------- HNWK -- HAWK Form 990-EZ(2019) Form 990-EZ(2019), DHWANI ACADEMY OF PERCUSSION MUSIC Pa go 3 Other Information (Note the Schedule A and personal benefit contract statement requirements in the instructions for Part V.)Check if the organization used Schedule O to respond to any question in this Part V. Yes No 33 Did the organization engage in any significant activity not previously reported to the IRS?If"Yes,"provide a detailed description of each activity in Schedule 0. . . . . . . . . . . . . . . . . . . . . . 33. X 34 Were any significant changes made to the organizing or governing documents?If"Yes," attach a conformed copy of the amended documents if they reflect a change to the organization's name.Otherwise,explain the change on Schedule 0.See instructions. . . . . . . . . . . . . . . . . . . . . . . . . , . 34 X 35 a Did the organization have unrelated business gross Income of$1,000 or more during the year from business activities(such as those reported on lines 2,6a,and 7a,among others)?. . . . . . . . . . . . . . . . . . 35a X b If"Yes"to line 35a,has the organization filed a Form 990-T for the year?If"No,"provide an explanation in Schedule 0. . . 35b I c Was the organization a section 501(c)(4),501(c)(5),or 501(c)(6)organization subject to section 6033(e)notice, j reporting,and proxy tax requirements during the year?If"Yes,"complete Schedule C,Part III. . . . . . . . 35c X 36 Did the organization undergo a liquidation,dissolution,termination,or significant disposition of net assets during the year?If"Yes," complete applicable parts of Schedule N. . . : . . . . , . . . . . . . . , 36 X 37 a Enter amount of political expenditures,direct or indirect,as described in the instructions. ► 37a � ' 4i ^!] b Did the organization file Form 1120-POL for this year?. . . . . . . . . . . . . . . . . . . . . . . . . 37b X 38 a Did the organization borrow from,or make,any loans to,any officer,director,trustee,or key employee;or were { any such loans made in a prior year and still outstanding at the end of the tax year covered by this return?. . . . 38a X b If"Yes,"complete Schedule L, Part II and enter the total amount involved. . . . . . . 38bnX^ a +' { 39 Section 501 c 7 organizations.Enter: R`r W Kr a Initiation fees and capital contributions included on line 9. 39a � x °�'E � r a b Gross receipts,included on line 9 for public use of club.facilities. 39b ffiv 40 a Section 501 c 3 organizations. Enter amount of tax Imposed on the organization duringthe year under: a ` RIB, section 4911 ► ;section 4912 OP- ;section 4955 ► °� �� b Section 501(c)(3),501(c)(4),and 501(c)(29)organizations,Did the organization engage in any section 4958 y „ excess benefit transaction during the year,or did it engage in an excess benefit transaction In a prior year that has not been reported on any of its prior Forms 990 or 990-EZ?If"Yes,"complete Schedule L,Part I . 40b X c Section 501(c)(3),501(c)(4),and 501(c)(29)organizations.Enter amount of tax imposed47 on organization managers or disqualified persons during the year under sections 4912, ��u x•��a'��1£ 4955,and 4958. . . . . . . . . . . . . . . . . . . . . . . . . . . . ► d Section 501(c)(3),501(c)(4),and 501(c)(29)organizations.Enter amount of tax on line 40c reimbursed by the organization. ► ,� •�� ;�:� e All organizations,At any time during the tax year,was the organization a party to a prohibited tax shelter transaction?If"Yes,"complete Form 8886-T. . . . . . . . . . . . . . . . . 40e X 41 List the states with which a copy of this return Is riled. ► 42 a The organization's books are In care of ► JYOTIPRAKASH MISTRI ------ _ Telephone no. Pp- Located at ► ---------------pity__CORONA St CA ZIP+4 ► 92882 b At any time during the calendar year,did the organization have an interest in or a signature or other authority over Yes No a financial account in a foreign country(such as a bank account,securities account,or other financial account)? 42b X If"Yes,"enter the name of the foreign country ► A ;t See the instructions for exceptions and filing requirements for FinCEN Form 114,Report of Foreign Bank and Financial Accounts(FBAR). � x, c At anytime during the calendar year,did the organization maintain an office outside the United States?. 42c X If"Yes,"enter the name of the foreign country ►_ 43 Section 4947(a)(1)nonexempt charitable trusts filing Form 990=EZ in lieu of Form 1041—Check here. ._.-- ► s and enter the amount of tax-exempt interest received or accrued during the tax year. . . . . . . . 10-1 43 Yes No "a Did the organization maintain any donor advised funds during the year?If"Yes,"Form 990 must be completed instead of Form 990-EZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44a X b Did the organization operate one or more hospital facilities during the year?If"Yes,"Form 990 must be LE M.��,�•'. ^ completed instead of Form 990-EZ.. . . . . . . . . . . . . . . . . . . . . . . . . : . 44b X c Did the organization receive any payments for indoor tanning services during the year? . . . . , . . . . . . 44c X d If"Yes"to line 44c, has the organization filed a Form 720 to report these payments?If"No,"provide an =REIM explanation in Schedule 0. . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . 44d X 45 a Did the organization have a controlled entity within the meaning of section 512(b)(13)?. . . . . . . . . . . . 45a X b Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)?If"Yes,"Form 990 and Schedule R may need to be completed instead of �� t ?4: Form 990-EZ.See instructions. 45b X Form 990-EZ(2o19) Form 990-EZ(2019) DHWANI ACADEMY OF PERCUSSION MUSIC Pa e 4 Yes No 46 Did the organization engage,directly or Indirectly, in political campaign activities on behalf of or in opposition xaR, to candidates for public office?If"Yes,"complete Schedule C,Part I.. 46 X MaM Section 501(c)(3)Organizations Only All section 501(c)(3)organizations must answer questions 47-49b and 52,and complete the tables for lines 50 and 51. Check if the organization used Schedule O to respond to any question in this Part VI . . . . . . . . . . . ❑ Yes No 47 Did the organization engage in lobbying activities or have a section 501(h)election in effect during the tax year?If"Yes,"complete Schedule C,Part II. . . . . . . . . . . . . . . .. . . , . . . . . 47 X 48 Is the organization a school as described in section 170(b)(1)(A)(€1)?If"Yes,"complete Schedule E. . . . . . 48 X 49 a Did the organization make any transfers to an exempt non-charitable related organization?. . . . . . . . 49a X b If"Yes,"was the related organization a section 527 organization?.. . . . . . . . . . . 49b 50 Complete this table for the organization's five highest compensated employees(other than officers,directors,trustees,and key employees)who each received more than$100,000 of compensation from the organization. If there is none,enter"None." j (b)Average (c)Reportable (d)Health benefits, (a)Name and title of each omployea hours per week compensation contdbutlons to employee (a)Eatimated amount of devoted to position (Forms W-211090-MISC) benefit plans,and deferred other compensation ' oompensailon Name None --------------------------------------------------------- Title HrNVK .00 --------------------------------------------------- Name Title Hr/WK .00 --------------------------------------------------- Name Title Hf1WK .00 -------------------------------------------------- Name Title Hr1WK .00 -------------------------------------------------- Nams Title HrNVK 00 f Total number of other employees paid over$100,000. . . . . . . . . . ► 51 Complete this table for the organization's five highest compensated independent contractors who each received more than $100,000 of compensation from the or anization. If there Is none,enter"None." (a)Name and business address of each independent contractor .(b)Type of service (c)Compensation Name None Sir - _ --------`------------------------------------------------------------------------------------------ city ST ZIP Noma Str . Ci ST ZIP Name Str cit ST ZIP j Name Sir -- ------- ---- -- -- - - ---------------------------------------------- CRY ST ZIP - Name Sir 1 --------------------------------------------------.---------------------------------- 1 city- ST ZIP 1 d Total number of other independent contractors each receiving over$100,000. . . . . . . ► 52 Did the organization complete Schedule A?Note:All section 601(c)(3)organizations must attach a completed Schedule A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ►0 Yes ❑ No Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,it Is he,correct,and complete.Declaration of preparer(other than officer)is based on all Information of which preparer has any knowledge. - r Sign Signature of officer Date Here 1 ABHIJIT BANERJEE 11/14/2018 Type or print name and title PrInUType prepares Check name Prepares's signature Date P71N Paid x if SUBHRA K BANERJEE ISUBHRA K BANERJEE 7/20/2020 self-ern la ed Preparer Firm'name to- S&A ASSOCIATES CPA'S Use Only Firms EIN Flrm's address ► LOS ANGELES,CA 90071 Phone no. May the IRS discuss this return with the preparer shown above?See instructions. . . . . . . . . . '. . . . .. ►❑ Yes ❑ No Form 990-EZ(2019) SIGHEDULE A OMB No.1545-0047 (Form 990 or 990-EZ) Public Charity Status and Public Support �O 1 Complete Ifthe organization Is a section 5o1(e)(3)organization or a section 4947(a)(1)noneKempt charitable trust. Department of the Treasury ►Attach to Form 990 or Form 990-5Z. ► ► Internal Revenue service ► Go to wwwJrs. ov1Form990 for Instructions and the latest information. Name of1he organization Employer Identification number DHWANI ACADEMY OF PERCUSSION MUSIC 07 Me Reason for Public Charity Status All organizations must complete this art. See instructions. The or anlzation is not a private foundation because it is:(For lines 1 through 12,check only one box.) 1 A church,convention of churches,or association of churches described in section 170(b)(1)(A)(i). 2 A school described in section 170(b)(1)(A)(11).(Attach Schedule E(Form 990 or 990-EZ).) 3 A hospital or a cooperative hospital service organization described In section 170(b)(1)(A)(iii). 4 A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii).Enter the hospital's name,city,and state: 5 An organization operated for the benefit of a college or university owned or operated by a governmental unit described In section 170(b)(1)(A)(iv).(Complete Part II.) 8 A federal,state,or local government or governmental unit described in section 170(b)(1)(A)(v). 7 An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi).(Complete Part II.) 8 A community trust described In section 170(b)(1)(A)(vi).(Complete Part 11.) 9 An agricultural research organization described in section 170(b)(1)(A)(Ix)operated in conjunction with a land-grant college or university or a non-land-grant college of agriculture(see instructions).Enter the name,city,and state of the college or university: ----------------------------------------a------------------------------ ----------- ------------------------------------------ 10 1^ An organization that normally receives:(1)mare than 33 113°!°of its support from contributions,membership fees,and gross receipts from activities related to Its exempt functions—subject to certain exceptions,and(2)no more than 33 1/3%of its support from gross Investment income and unrelated business taxable income(less section 511 tax)from businesses acquired by the organization after June 30, 1975.See section 509(a)(2).(Complete Part III.) 11 An organization organized and operated exclusively to test for public safety.See section 509(a)(4). 12 An organization organized and operated exclusively for the benefit of,to perform the functions of,or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1)or section 509(a)(2).See section 509(a)(3). Check the box In lines 12a through 12d that describes the type of supporting organization and complete Ines 12e, 12f,and 12g. a ❑ Type 1.A supporting organization operated,supervised,or controlled by€ts supported organization(s),typically by giving the supported organization(s)the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization.You must complete Part IV,Sections A and B. b Type II.A supporting organization supervised or controlled in connection with its supported organization(s),by having control or management of the supporting organization vested in the same persons that control or manage the supported organlzation(s).You must complete Part IV,Sections A and C. c El Type III functionally integrated.A supporting organization operated In connection with,and functionally integrated with, i its supported organization(s)(see instructions).You must complete Part IV,Sections A,D,and E. d ❑Type III non-functionally integrated.A supporting organization operated in connection with its supported organization(s) that is not functionally integrated.The organization generally must satisfy a distribution requirement and an attentiveness 1 requirement(see instructions).You must complete Part IV,Sections A and D,and Part V. e 0 Check this box if the organization received a written determination from the IRS that it is a Type I,Type 11,Type III functionally integrated,or Type III non-function ally integrated supporting organization. f Enter the number of supported organizations. . . . , . . . . . . . . . . . . . . . . . . , . . . Provide the followIna information about the supported or anizations. (i)Name of supported organization (II)EIN (111)Type of organization (Iv)lathe organization (v)Amount of monetary (A)Amount of s (described on lines 1-10 listed in your governing support(see other support(see above(sea instructlons)) document? Instructions) Instructions) Yes No (A) (B) M (D) (E) Total w�F �p ar +' cn?, �k , F a a �. xAll For Paperwork Reduction Act Notice,see the Instructions for Form 990 or 990-EZ. schedule A(Form 990 or 990-FZ)2019 HTA Schedule A(Form 990 or 990-EZ)2019 DI-IWAN I ACADEMY OF PERCUSSION MUSIC Page 2 Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv)and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization-fails to qualify under the tests listed below, please complete Part III. Section A. Public Support- Calendar year.(or fiscal year beginning in) 1► a 2015 b 2016 c 2017 d 2018 a 2019 Total 1 Gifts,grants,contributions,and membership fees received.(Do not include any"unusual grants."). . . . . 0 2 Tax revenues levied for the organization's benefit and either paid to or expended on Its behalf. . . . . . 0 3 The value of services or facilities furnished by a governmental unit to the organization without charge. . . . . . 0 4 Total.Add lines 1 through 3 . . . . . . 0 0 0 0 0 0 5 The portion of total contributions by u yf � a `y ` k r � ifia em �tr � each person(other than aya 1 governmental unit or publicly �2e \ ha o u � err`v i 51 y supported organization)included on 4101 »�\, line 1 that exceeds 2%of the amount x $ t �� z g 4y2 anya U tbP � 4c� shown on line,ll,COIUmr }. a s h �,��t "``�p`�-?'�^ `,� :� 0 �a'"�xt' 6 Public support.Subtract line 5 from line 4 1 t 21A 1.1 tiw ix „� .l10 �. .,11110 ,1 A,a. <, ,,10 0 Section 13.Total Support Calendar year(or fiscal year beginning in) 1► a 2015 b 2016 a 2017 d 2018 a 2019 Total i 7 Amounts from line 4.. . . . . . . . . 0 0 0 0 0 0 8 Gross income from interest,dividends, payments received on securities loans, rents,royalties,and income from similar sources. . . . . . . . . . . 0 9 Net Income from unrelated business activities,whether or not the business is regularly carried on. . . . . . . . . 0 10 Other Income. Do not Include gain or loss from the sale of capital assets (Explain in Part VI.). . . . . . . . . 0 11 Total support.Add lines 7 through 10 �,fa .'ti` `t. �� „ - <, x a'. i °$ 0 12 Gross receipts from related activities,etc.(see instructions). . . . . . . . . . . . . . . . . . . . 12 j 13 First five years.If the Form 990 is for the organization's first,second,third,fourth,or fifth tax year as a section 601(c)(3) organization,check this box and stop here. . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . .► ? Section C.Computation of Public Support Percentage 14 Public support percentage for 2019(line 6,column(f)divided by line 11,column(q). . . . . . . . . . . . 14 0.00% 15 Public support percentage from 2018 Schedule A,Part II,line 14... . . . . . . . . . . . . . . . . . . 15 0.00% 16a 33 113%support test-2019.If the organization did not check the box on line.13,,and line 14 is 33 113%or more,check this box and stop here.The organization qualifies as a publicly.supported organization. . . . . . . . . . . . . . . . . . . . . . . . . . . .►❑ b 33 113%support test 2018.If the organization did not check a box online 13 or 16a,and line 15 is 33 113%or more,check this box and stop here.The organization qualifies as a publicly supported organization. . . . . . . . . . . . . . . . . . . . . . . . . ►❑ 17a 10%-facts-and-circumstances test-2019.If the organization did not check a box on line 13,16a,or 16b,and line 14 10%or more,and if the organization meets the"facts-and-circumstances"test,check this box and stop here.Explain In Part VI how the organization meets the"facts and-circumstances"test.The organization qualifies as a publicly supported organization.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ►❑ b 10%-facts-and-circumstances teat 2018.If the organization did not check a box on line 13,1 Be.16b,or 17a,and line 15 is 10%or more,and if the organization meets the"facts-and-circumstances"lest,chock this box and stop here. Explain in Part VI how the organization meets the"facts-and-circumstances"test.The organization qualifies as a publicly supported organization. . . . . . . . . . . . . . . . . . . . . . '. . . . . . . . . . . . . . . . . . . . . . . . . . ►❑ 18 Private foundation.If the organization did not check a box on line 13,16a,16b,17a,or 17b,check this box and see Instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ►❑ Schedule A(Form 990 or BOO-EZ)2019 Schedule A(Form 990 or 990-EZ)2019 DHWANI ACADEMY OF PERCUSSION MUSIC M page 3 Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part.l I. If the organization fails to gualify under the tests listed below, please oom late Part.II. Section A. Public Support Calendar year(or fiscal year beginning in) ► a 2015 b 2016 c 2017 cl 2018 a 2019 Total 1 Gifts,grants,contributions,and membership fees received,(Do not include any"unusual grants.") 12,400 10,000 10,000 10,000 73,950 116,350 2 Gross receipts from admissions,merchandise sold or services performed,or fecllitles furnished In any eclivity that Is related to the k organization's tax-exempt purpose. . . , . 95,344 101,911 112177 99,740 78366 487,538 3 Gross receipts from activities that are not an unrelated trade or business under section 513. 0 4 Tax revenues levied for the organization's beneflt and either paid to or expended on its behalf. . . . . . . 0 5 The value of services or facilities furnished by a governmental unit to the } organization without charge. . . . . . 0 6 Total.Add lines 1 through 5. . . . . . 107,744 111,911 122,177 109,740 152,316 603,888 7a Amounts Included on.lines 1,2,and 3 received from disqualified persons. . . 0 b Amounts Included on lines 2 and 3 received from other than disqualified persons that exceed the greater of$5,000 or 1%of the amount on line 13 for the year. . . 0 c Add lines 7a and 7b. . . , , . , . 01 01 01 0 0 0 8 Public support(Subtract line 7c from line 6.1' � x 603,888 l � �1•... �...9. Section B.Total Support Calendar year(or fiscal year beginning in) ► a 2015 b 2016 c 2017 d 2018 e.2019 Total 9 Amounts from line 6. . . . . . . . . 107,744 111,911 122,177 109,740 152,316 603,888 10a Gross income from interest,dividends, payments received on securities loans,rents, royalties,and income from similar sources. . . 0 b Unrelated business taxable income(less section 511 taxes)from businesses acquired after June 30,1975 . . . . . 0 E c Add lines 10a and 10b. . . . . . . . 0 0 0 0 0 0 11 Net income from unrelated business activities not included in line 10b,whether or not the business is regularly carried on. 0 12 Other income.Do not include gain or loss from the sale of capital assets I {Explain in Part VI.). 0 13 Total support.(Add lines 9,10c,11, and 12,). . . . . . . . . . . . . . 167,744 111,9111 122,177 109,7401 152,3 66 603,888 14 First five years.If the Form 990 is for the organization's first,second,third,fourth,or fifth tax year as a section 501(c)(3) organization,check this box and stop here. . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .► Section C.Com utation of public Support Percentage 15 Public support percentage for 2019(line 8,column(0,divided byline 13,column(Fy). . . . . . . . . . . . 15 100.00% 16 Public support percentage from 2018 Schedule A,Part III,line 15. 16 100,00% Section D.Computation of Investment Income Percentage 17 Investment Income percentage for 2019(fine 10c,column(f),divided by line 13,column(f)). . . . . . . . , 17 0,00°% 18 Investment income percentage from 2018 Schedule A,Part 111,fine 17. . . . . . . . . . . . . . . 18 0.00% 19a 33 113%support tests 2019.If the organization did not check the box online 14,and line 15 Is more than 33 113%,and line 17 is not more than 33 113%,check this box and stop here.The organization qualifies as a publicly supported organization. . . . . . . . . . . . . Jo- FX b 33 113%support tests 2018.If the organization did not check a box on line 14 or line 19a,and line 16 Is more than 33 113%,and line 18 is not more than 33 113%,check this box and stop here.The organization quallfles as a publicly supported organization. . . . . . . . . ► 20 Private foundation.If lho organization did not check a box on line 14,19a,or 19b,check this box and see instructions. . . . . . , . . ► Schedule A(Form 990 or 999-EZ)2010 Schedule A(Form 990 or 990-FZ)2019 DHWANI ACADEMY OF PERCUSSION MUSIC Pae4 Supporting Organizations (Complete only if you checked a box in line 12 on Part 1. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part 1,complete Sections A, D, and E. If you checked 12d of Part.] complete Sections.A and D,and complete Part V. Section A.All Supporting Organizations Yes No 1 Are all of the organization's supported organizations listed by name In the organization's governing F ` documents?If No,"describe in Part VI haw the supported organizations are designated. If designated by class or purpose,describe the designation.If historic and continuing relationship,explain. 1 2 Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1)or(2)?If"Yes,"explain in Part W how the organization determined that'the supported organization was described in section 509(a)(1)or(2). 2 3a Did the organization hale a supported organization described in section 501(c)(4),(5),or(6)?If"Yes,"answer M (b)and(c)below. 3a b Did the organization confirm that each supported organization qualified under section 501(d)(4),(5),or(6)and satisfied the public support tests under section 509(a)(2)?If"Yes,"describe in Part V1 when and how the A ti,sR organization made the determination. 3b ,. j c Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2) (B)purposes?If"Yes,"explairi In Part VI what controls the organization put in place to ensure such use. 3c 4a Was any supported organization not organized in the United States("foreign supported organization")?If "Yes,"and if you checked 129 or 12b in Part 1,answer(b)and(c)below. 4a b Did-the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization?If"Yes,"describe in Part Vt how the organization had such control and discretion, despite being controlled or supervised by or in connection with its supported organizations. 4b c Did the organization support any foreign supported organization that does not have an IRS determinationRt s under sections 501(c)(3)and 509(a)(1)or(2)?If Yes, explain in Part Vt what controls the organization usedi \\ a �Z to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes. 4c 5a Did the organization'add,substitute,or remove any supported organizations during the tax year?If"Yes," ( J (J ( applicable). A g() answer b and c below !f a Iicable.Also,provide detail in Part including ! the names and E1N � wo ,r , numbers of the supported organizations added,substituted, or removed;(h)the reasons for each such action; �` N �yc; (!i!)the authority under the organization's organizing document authorizing such action;and(iv)how the action was accomplished(such as by amendment to the organizing document). 5a b Type I or Type II only.Was any added or substituted supported organization part of a class already designated In the organization's organizing document? 5b c Substitutions only.Was the substitution the result of an event beyond the organization's control? Sc 6 Did the organization provide support(whether in the form of grants or the provision of services or facilities)to AN anyone other than(1)Its supported organizations,(ii)individuals that are part of the charitable class benefited by one or more of its supported organizations,or(111)other supporting organizations that also support or 2 benefit one or more of the filing organization's supported organizations?If"Yes,"provide detail in Part VI. 6 j 7 Did the organization provide a grant,loan,compensation,or other similar payment to a substantial contributorfi as defined in section 4958 c 3 C a familymember of a substantial contributor or a 35%controlled entit �a with regard to a substantl al.contributor?If"Yes,"complete Part I of Schedule L'(Form 990 or 990-EZ). 7 1 8 Did the organization make a loan to a disqualified person as defined In section 4958 not described In line 7? g q P ( } If"Yes,"complete Part I of Schedule L(Form 990 or 990-EZ). 8 9a Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined In section 4946(other than foundation managers and organizations described In section 509(a)(1)or(2))?If"Yes,"provide detail in Part V1. 9a b Did one or more disqualified persons(as defined in line 9a)hold a controlling interest in any entity in which M„ w 4 ,. the supporting organization had an Interest?If"Yes,"provide detail in Part V1. 9b c bid a disqualified person(as defined in line 9a)nave an ownership interest in,or derive any personal benefit = ;<. from,assets In which the supporting organization also had an.interest?If"Yes,"provide detail in Part Vt. 9c 10a Was the organization subject to the excess business holdings rules of section 4943 because of section : 4 4943(f)(regarding certain Type II supporting organizations and all Type III non-functionally integrated supporting organizations)?If"Yes,"answer 10b below. 10a b Did the organization have any excess business holdings in the tax year?(Use Schedule C,Form 4720,to determine whether the organization had excess business holdings.) 10b Schedule A(Form 990 or 990-:Z)2019 Schedule A(Form 990 or 990-EZ)2019 DHWANI ACADEMY OF PERCUSSION MUSIC Pa e 5 RM Supporting Organizations continued JYesJ No 11 Has the organization accepted a gift or contribution from.any of the following persons? 4S a A person who directly or indirectly controls,either alone or together with persons described In(b)and(c) r below,the governing body of a supported organization? Ila b A family member of a person described in(a)above? 9l b c A 35%controlled entity of a person described in a or 6 above?If"Yes"to a,b,or c,provide detail in Part W. Ile Section B.Type I Supporting Organizations Yes No 1 Did the directors,trustees,or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization's directors or trustees at all times during the 9 Y PP J Y 9 g tax year?If"No,"describe in Part V1 haw the supported organization(s)effectively operated,supervised,or ;. controlled the organization's activities.If the organization had mare than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported z organizations and what conditions or restrictions,if any,applied to such powers during the tax year. 1 2 Did the organization operate for the benefit of any supported organization other than the supported 1 organizatlon(s)that operated,supervised,or controlled the supporting organization?if"Yes,"explain in Part ' W how providing such benefit carried out the purposes of the supported organization(s)that operated, rb' supervised,or controlled the supporting organization. 2 Section C.Type II Supporting Organizations j Yes No 1 Were a majority of the organization's directors or trustees during the tax year also a majority of the directors or trustees of each of the organization's supported organization(s)?If"No,"describe In Part V1 how control > �S or management of the supporting organization was vested in the same persons that controlled or managed as the supported organization(s). 1 Section D.All Type III Supporting Organizations Yes No 1 Did the organization provide to each of its supported organizations,by the last day of the fifth month of the organization's tax year,(1)a written notice describing the type and amount of support provided during the prior tax year,(li)a copy of the Form 990 that was most recently filed as of the date of notification,and(1i))copies of the organization's governing documents In effect on the date of notification,to the extent not previously provided? 1 2 Were any of the organization's officers,directors,or trustees either(i)appointed or elected by the supported organization(s)or(1I)serving on the governing body of a supported organization?if"No,"explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s). 2 3 By reason of the relationship described In(2),did the organization's supported organizations have a �� k{' significant voice in the organizations investment policies and in directing the use of the organization's income or assets at all times during the-tax year?If"Yes,"describe in Part V1 the role the organization's � �� supported organizations played in this regard. 3 Section E.Type III Functionally Integrated Supporting Organizations I Check the box next to the method that the organization used to satisfy the Integral Part Test during the year(see instructions). a The organization satisfied the Activities Test.Complete line 2 below. j b The organization is the parent of each of its supported organizations.Complete line 3 below. c The organization supported a governmental entity.Describe in Part W how you supported a government entity(see instructions). 2 Activities Test.Answer(a)and(b)below. Yes No a Did substantially all of the organization's activities during the tax year directly further the exempt purposes of the supported organizatlon(s)to which the organization was responsive?If"Yes,"then in Part W identify z y i those supported organizations and explain how those activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations,and how the organization determined " -I"." Ilk :..,... that these activities constituted substantially all of its activities. 2a b Did the activities described in(a)constitute activities that,but for the organization's involvement,one or more of the organization's supported organlzation(s)would have been engaged In?If"Yes,"explain in Part V1 the reasons for the organization's position that its supported organization(s)would have engaged in these activities but for the organizations involvement. 2b 3 Parent of Supported Organizations.Answer(a)and(b)below. k' a Did the organization have the power to regularly appoint or elect a majority of the officers,directors,or trustees of each of the supported organizations?Provide details in Part V1. 3, b Did the organization exercise a substantial degree of direction over the policies,programs,and activities of each rex `2 �r of its supported organizations?If Yes,"describe in Part V1 the role la ed by the organization in this regard. 3b Schedule A(Form 990 or 990-EZ)2019 Schedule (Form 990or990-EZ)2019 DHWANI ACADEMY OF PERCUSSION MUSIC Pa e 6 RM Two III Non-Functionally Integrated 509(a)(3)SUpporting Organizations 1 Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov.20, 1970(explain in Part VI).See Instructions.All other T pe III rion-functionally integrated supporting organizations must complete Sections A through E. Section A-Adjusted Net Income (A)Prior Year (B)Current Year (optional) 1 Net short-term capital a€n 1 2 Recoveries of rior- ear.distributions 2 3 Other gross Income see instructions 3 4 Add lines 1 through 3. 4 0 0 5 Depreciation and depletion 5 6 Portion of operating expenses paid or incurred for production or collection of gross Income or for management,conservation,or maintenance of property held for production of income(see instructions) 6 7 Other expenses see instructions 7 6 Adjusted Net Income subtract lines 5,6,and 7 from line 4). 8 0 0 Section B-Minimum Asset Amount (A)Prior Year (B)Current Year (optional) 1 Aggregate fair market value of all non-exempt-use assets(see ` ? `RV "� instructions for short tax year or assets held for part of year): w� axe y" a Average monthly value of securities 1a b Average monthly cash balances 1b c Fair market value of other non-exempt-use assets 1c 1 d Total add lines 1a,1b,and 1c 1d 0 0 e Discount claimed for blockage or other � ao �h9 factors(explain in detail in Part Vl : Mt � �w 2 Acquisition indebtedness applicable to non-exempt-use assets 2 3 Subtract line 2 from line 1d. 3 0 0 4 Cash deemed held for exempt use. Enter 1-1J2%of line 3(for greater amount, see instructions). 4 0 0 5 Net value of non-exempt-use assets subtract line 4 from line 3 5 0 0 6 Multiply line 5 b .035. 6 0 0 7 Recoveries of prior-year distributions 7 0 0 8 Minimum Asset Amount add line 7 to line 6 8 0 0 Section C-Distributable Amount �w� Current Year 1 Adjusted net income for rior ear from Section A,line 8,Column A 1 �� N l o 2 Enter 85%of line 1 2 ' 1 3 Minimum asset amount for prior year from Section B dine 8,Column A 3a .. b 0 4 Enter greater of line 2 or line 3. 4 0 5 Income tax Imposed in prior year 5 6 Distributable Amount.Subtract line 5 from line 4,unless subject to a � ; emergency temporaryreduction see Instructions). 6 ° 0 7 Check here if the current year Is the organization's first as a non-functionally integrated Type III supporting organization(see Instructions). Schedule A(Form 990 or 990•PZ)2019 Schedule A(Form 990 or 990-EZ)2019 DHWANI ACADEMY OF PERCUSSION MUSIC page 7 T e III Non-Functional) Integrated 509 a 3 Supporting Organizations conffnued Section D-Distributions Current Year 1 Amounts paid to su orted organizations to accomplish lish exempt purposes 2 Amounts paid to perform activity that directly furthers exempt purposes of supported or anizations,in excess oflncome from activity 3 Administrative expenses eald to accom lisp exempt puEposes of sueported organizations 4 Amounts paid to acquire exempt-use assets 5 Qualified set-aside amounts(prior IRS approval required) 6 Other distributions describe in Part VI).See instructions. 7 Total annual distributions.Add lines 1 through 6. 0 8 Distributions to attentive supported'organizations to which the organization is responsive (provide details in Part VI).See instructions. 9 Distributable amount for 2019 from Section C line 6 0 10. Line 8 amount divided by line 9 amount 0.000 Section E-Distribution Allocations(see Instructions) Excess Distributions Underdistributions Distributable Pre-2019 Amount for 2019 l 1 Distributable amount for 2019 from Section C,line 6 0 2 Underdistrlbutions,if any,for years prior to 2019 (reasonable cause required—explaln In Part VI).See Instructions. j 3 Excess distributions carryover,if any,to 2019 'sN1 A a From 2014, 0 X£ a;,w'.w'' " '°i x;,S b From 2015. 0 �Z c From 2016. 0 :x^5 :."o%a�"1n.,�` i` a`sw,,` `"�., �' iOw`,.,M\ S"�+ ri.; �...�.$a. d From 2017. 0 e From 2018. 0 Total of lines 3a through e 0 }a; ti h y g Wit@ `;gym a��axaF,aY ,c'r..;t Applied to underdistributions of prior ears � � .��,x„ �.s�.�� x�, 0 h A Iled to 2019 distributable amountM ,. kz e�A $ 0 i Carryover from 2014 not applied see Instructions �;�u� �wah\" a,w Remainder.Subtract Tines 3 ,3h,and 31 from 3f. 0 L �4 Distributions for 2019 from „� Kfi�� ,� a ,� � sM Section D,line 7: $ 0 �?�� 10 "xX a Applied to underdistributions of prior years ��', ��a,z��` � 0 b Applied to 2019 distributable amount u � < � y � + ,r 0 c Remainder.Subtract lines 4a and 4b from 4. 0 HIM. a�� 5 Remaining underdistribufionsfoi years prior to 2019;if z� , ��U� any.Subtract lines 3g and 4a from line 2.For results greater than zero,explain In Part VI.See Instructions. �s�' � & .,, 0 s�\ r 6 Remaining undeniistributionsfoi 2019.Subtract lines 3h ��\��`0_� and 4b from Tine 1.For result greater than zero,explain Part VI.See Instructions. ?:;, � .::;. � .� �� 0 I 7 Excess distributions carryover to 2020.Add lines 3j � � k ' F �� z a1V;��k ��13 and 4C. - _ 0M.: 8 Breakdown of line 7: a Excess from 2015. 0 da � ,� tF5 b Excess from 2016. 0 �' R\1� P who e �7 w < �. ,:•a .a F;ea - c Excess from 2017. 0 d Excess from 2018. 0 ,E r`° "MRS-9 ` i w a a1` a \r a 's,�2 �ati�( w" �,`pan e Excess from 2019. O wY+�k�,A�> �,�0�<�„ .�t.a��N�e:�,w=��<x k C?, .-1A e 1��z. Schedule A(Form 990 or BOO-EZ)2019 Schedule A(Form 990 or990-EZ)2019 DHWANI ACADEMY OF PERCUSSION MUSIC Pa e 8 Supplemental Information,Provide the explanations required by Part II,line 10;Part II,line 17a or 17b;Part III,line 12;Part IV,Section A,lines 1,2,3b,3c,4b,4c,5a,6,9a,9b,9c, 11a,11b,and 11c;Part IV,Section B,lines 1 and 2;Part IV,Section C,line 1; Part IV,Section D,lines 2 and 3;Part IV,Section E,lines 1c,2a,2b, 3a,and 3b;Part V,line 1; Part V,Section B,line 1e;'Part V,Section D,lines 5,6,and S;and Part V,Section E, lines 2,5,and 6.Also complete this part for any additional information. See instructions. ------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------=--------------------------- - Y ------------------------------------------------------------------------------------------------------------------------------------------------ f ------------------------------------------------------------------------------------------------------------------------------=-----.------------ i ------------------------------------------------------------------------------------------------------------------------------------------------- j 1 ----------------------------------------------------------------------------------------------------------'-------------------------------------- 1 -------------------------------------------------- -----------------------------------------------------------------------------_--------------- ------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------- i I ---------------------------------------------------------------------------------------------------------------------------------------------- - �I I ------------------------------------------------------------------------------------------------------------------------------------------------ i --------------------------------------------_---------------------------------------------------------------------------------------------------- I ------------------------------------------------------------------------------------------------------------------------------------------------ { j - ----------___..___:- - ------------------------------- ----------------------- j -------------•------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------ --------------------------------------------------------------------------------------------- -------------------------------------------------------- --------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------- schedule A(Form 990 or 990•EZ)2019 Schedule B Schedule of Contributors OMB Nu.1545-0047 (Form 990,990-EZ, or 990-PF) ► Attach to Form 990,Form 990-EZ,or Form 990-13F. 2A 9 us Service pepartmenrorthsTreasury Internet Reven ► Gotowwov.irs.g ov/Form980forthelatestinfarmation. Name of the organization Employer identification number DHWANI ACADEMY OF PERCUSSION MUSIC Organization type(check one); Filers of: Section: Form 990 or 990-EZ X❑ 501(c)( 3 )(enter number)organization 4947(a)(1)nonexempt charitable trust not treated as a private foundation 527 political organization Form 990-PF ❑ 501(c)(3)exempt private foundation I 4947(a)(1)nonexempt charitable trust treated as a private foundation 501(c)(3)taxable private foundation f I' Check if your organization is covered by the General Rule or a Special Rule. Note:Only a section 501(c)(7),(8),or(10)organization can check boxes for both the General Rule and a Special Rule.See instructions. General Rule For an organization filing Form 990,990-EZ,or 990-PF that received,during the year,contributions totaling$5,000 or more(in money or property)from any one contributor.Complete Parts I and II.See instructions for determining a contributor's total contributions. Special Rules For an organization described in section 501(c)(3)filing Form 990 or 990-EZ that mot the 33 113%support test of the regulations under sections 509(a)(1)and 170(b)(1)(A)(vi),that checked Schedule A(Form 990 or 990-EZ),Part II,line 13, 16a,or 16b,and that received from any one contributor,during the year,total contributions of the greater of(1) $5,000;or(2)2%of the amount on(1)Form 990,Part VI II,line 1h;or(i€)Form 990-EZ,line 1.Complete Parts I and 11. For an organization described.in section 501(c)(7),(8),or(10)filing Form 990 or 990-EZ that received from any one contributor,during the year,total contr€butions of more than$1,000 exclusively for religious,charitable,scientific, I literary,or educational purposes,or for the prevention of cruelty to children or animals.Complete Parts I, II,and Ill. El For an organization described in section 501(c)(7),(8),or(10)filing Form 990 or 990-EZ that received from any one � contributor,during the year,contributions exclusively for religious,charitable,etc.,purposes,but no such contributions totaled more than$1,000. If this box is checked,enter here the total contributions that were received during the yearforan exclusively religious,charitable,etc.,purpose.Don't-complete any of the parts unless the General Rule applies to this organization because It received nonexclusively religious,charitable,etc.,contributions totaling$5,000 or more during the year. . . . . .. . . . . . . . . . . . . . . . . . . . IN. $ -------------------------- Caution:An organization that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B(Form 990, 990-EZ,or 990-PF),but it must answer"No"on Part IV,line 2,of its Form 990;or check the box on line H of its Form 990-EZ or on its Form 990-PF,Part I,line 2,to certify that it doesn't meet the filing requirements of Schedule B(Form 990,990-EZ,or 990-PF). For Paperwork Reduction Act Notice,see the instructions for Form 990,990-r-Z,or 990-PF. Schedule B(Form 990,990-EZ,or 990-PF)(2019) HTA Schedule B(Form 990,990-EZ,or 990-PF)(2019) Page 2 Name of organization Employer identification number DHWANI ACADEMY of PERCUSSION MUSIC Contributors (see instructions). Use duplicate copies of Part I if additional space is needed. (a) (b) (c) (d) No. Name,address,and ZIP+4 Total contributions Type of contribution Person ❑ ------- ------------------ - _ Payroll ❑ ------ --- ------ --- -- Noncash ❑ Foreign Stale or Province; (Complete Part II for a Foreign Country:_______________________________________ noncash contributions.) (a) (b) (c) (d) . No. Name,address,and ZIP+4 Total contributions Type of contribution --------------------------------------------------------- Person ❑ 3 ---------------------------- ------ Payroll ❑ - ---------- Noncash � Foreign State or Province: ________________ _____________ (Complete Part II for Foreign Country:....................... noncash contributions.) ----------------- (a) (b) (c) (d) No. Name,address,and ZIP+4 Total contributions Type of contribution ----- - - - - -- - - - - - Person ❑ Payroll ❑ -------------------------.------------------------------ ❑ $---------------------------,.._- Noncash Foreign State or Province: ________________ (Complete Part II for Foreign Country:________________________________________ noncash contributions.) (a) (b) (c) (d) . No. Name,address,and ZIP+4 Total contributions Type of contribution -- - --- - ------ ---- ----- --- -- - --- - --- Person ❑ •--�----------------------- -------------------------------- Payroll --------------------------------------------------------- --- Noncash ❑ Foreign State or Province: .............................. (Complete Part Ilfor Foreign Country:--- ----------------------------------- noncash contributions.) (a) (b) (e) (d) No. Name,address,and ZIP+4 Total contributions Type of contribution Person ❑ _ Payroll ❑ --------------- ----------------------------------------- El�--------------------------- -.- Noncash Foreign State or Province: ____________ (Complete Part II for Foreign Country:_____________________ noncash contributions.) (a) (b) (c) (d) No. Name,address,and ZIP+4 Total contributions Type of contribution -------- --------------------------------- ----------------------- Person ❑ Payroll ❑ -------__._-- �-------------------------____-- Noncash Foreign Stale or Province: _________ (Complete Part 11 for Foreign Country:____ - noncash contributions.) Schedule B(Farm 990,990-EZ,or 990-PF)(2019) Schedule B(Form 990,990-EZ,or 990-PF)(2019) Page 3 Name of organization Employer identification number DHWANI ACADEMY OF PERCUSSION MUSIC Noncash Property(see instructions). Use duplicate copies of Part II if additional space is needed. (a)No. b (c) ( ) Part I (See from Description of noncash property given FMV(instructions.)or estimate) Datereceived --------- ------------------------------------------------1------------ ------------------------------------------------------- ------------------------------------------ - $-- - (a)No. b (c) (d) Part I (See from Description of noncash property given FMV(instructions.)or estimate) Date received ,I I --------»---------------------------------------------------- --------- -----------------------------------------------»------------- I ------------------------------------------------------------- - --- =- ----- -- -» - - ------------------------------- ---------------------------- ----------------------' ---- i (a)No. b (c) from Description of noncash roe FMV(or estimate) (d) Part I p property given (See instructions.) Date received ------------------------------------------------------------- ---------------------------------------- - $,_ _ (a)No. b (c) from Description of noncash property FMV(or estimate) (d) Part I p P P y given (See instructions.) Date received i ------------------------------------------------------------- --------------------_------------------------------_---------- ----------------------- -------=----------------------------- $ ----------------------------- ------------_---------------- (a)No. (c)from (b) FMV(or estimate) O d Description of noncash property given Part I (See instructions.) Date received 1 ------------------------------------------------------------- i ------------------------------------------------- 9 __»------------------------------- -------------------------- ---------------------------------------------------- - $.-- (a)No. (c) ) from Description of noncash property given FMV(or estimate) Datereceived Part I (See instructions.) -------- ------------------------------------------------------------ ---------------------------------------------------------- ---------------------------------»--------------------------- $------------------------ - - Schedule B(Form 990,990-EZ,or 990•PF)(2019) Schedule B(Form 990,990-EZ,or 990-PF)(2019) Page 4 Name of organization Employer Identification number DHWANI ACADEMY OF PERCUSSION MUSIC Exclusively religious,charitable,etc.,contributions to organizations described in section 501(c)(7),(8),or (10)that total more than$1,000 for the year from any one contributor.Complete columns(a)through(e)and. the following line entry.For organizations completing Part III,enter the total of exclusively religious,charitable,etc., contributions of$1,000 or less for the year.(Enter this information once.See instructions.) ► $ 0 -------------------------- Use duplicate copies of Part III if additional space is needed. (a)No. from (b)Purpose of gift (c)Use of gift (d)Description of how gift is held Part I ----------------------------------------- ------------------------------------ ---------_------------------------------ (e)Transfer of gift Transferee's name,address,and ZIP+4 Relationship of transferor to transferee -------------------------------------------------------- E ------------------..___------------------------------------------------------ .--------------------------------- ------------------------------------------------------- ------------------------------------ �------------------ ------------------------------------------------------- For.Prov. Country (a)No. from Part (b)Purpose of gift (c)Use of gift (d)Description of how gift is held • ----------------------------------------- ------------------------------------ ---------------------------------------- (e)Transfer.of gift Transferee's name,address,and ZIP+4 Relationship of transferor to transferee -------------------------------------------------------- --------------------------=----------- ---------------_----------- -------------------------------------------------------- ------------------------------------------------------ ._. .__----- For.Prov. Country (a)No. from (b)Purpose of gift (c)Use of gift (d)Description of how gift is held Part ----------------------------------------- ------------------------------------ ------------------------------------- - ---- -----------------------------_------------ ------------------------------------ ------------------ __----------- = j ---------------------------------------- - ---------------------------------- ----------------------------------------- (e)Transfer of gift i Transferee's name,address,and ZIP+4 Relationship of transferor to transferee ------=-----------------------..._---------------=------- - -- --- -----------------------------------_--------------------- --------------------------------------------------------- - -- --- --------------------------------------.___-----_--------- For.Prov. Country (a)No. from (b)Purpose of gift (a)Use of gift (d)Description of how gift is held Part ----------------------------------------- -------------------------------------- ----------------------------------------- --------- ----------------------------------------- ------------------------------------ -__..__--------------------------------- ----------------------------------------- --------------------- -------------- --------_--__---------------------------- (e)Transfer of gift Transferee's name,address,and ZIP+4 Relationship of transferor to transferee -------------------------------------------------------- -- - --- ---------------------------------------------------------- For.Prov. Country Schedule B(Form 990,990-EZ,or 990-13F)(2010) SCHEDULE o Supplemental Information to Form 990 or 990-EZ (Form 990 or.990-EZ) Complete to provide information for responses to specific questions on ®� Form 990 or 990-EZ or to provide any additional Information. 0-Attach to Form 990 or 990-EZ. Department of the Treasury Go to www_irs. ov/Porm990 for the latest Information. Internal Revenue Service - Name of the organization Employer Iden i fication number DHWANI ACADEMY OF PERCUSSION MUSIC Form 990_EZ,Part 1,Line 16,Other Expenses:Travel_8,383 _ - ------------------------------------------------------------------- Form 990_EZ,Part I,Line 16.Other Expenses: Meals and entertainment:252 Form 990_EZ, Part I,Line 16,Other Expenses:Conferences,conventions,and meetings:225 Form 990_EZ,Part I,Line 16,Other Expenses_Supplies:23 i -------------------------------------------------------------------------- Form 990-EZ,Part I,Line 16,Other Expenses:Telephone:648 Form 990-EZ,Part t, Line 16,Other Expenses:Parkina_600 ] - - -- -- --- ---------------------------------------------------- Form 990-EZ,Part I,Line 16,Other Expenses:Office Expense_5,040 _ _ ________-.__ . I Form 990-EZ,Part I,Line 16�Other Expenses_ License Permits&Fees__1,388 Form 990_EZ, Part I,Line 16,Other Expenses:Lease Expense;4,500 - - --------------------.._------------------------------- Form 990_EZ,Part I, Line 16,Other Expenses: Internet Expense_934 -------------------------------------------------------------------. Form 990_EZ,Part 1,Llne 16,Other Expenses: Insurance:5,430 ------------------------------------------------___---------------------- Form 990-EZ,Part I,Line 16,.Other Expenses_ Dues&Subscription:- -- --- - ----- --- -- - - - -- -- -- -- - - ------------------------------------------------------ Form 990-EZ, Part I,Line 16,Other Expenses_Auto Expense:5,182 - -- --- ------ --- -- ----------------------------------------------------- Form 990_EZ,Part I,Line 16,Other Expenses_Bank Charges_502 _ - --------------------------------------___-. Form 990_EZ,Part I,Line 16.Other Expenses:Accounting Fees_2,100 1 Form 990_EZ,Part I,Line 16,Other Expenses:Program Expenses_41 _ i Form 990_EZ,Part I,Line 16,Other Expenses_ Utilities_717 Form 990_EZ,Part I,Line 16,Other Expenses:Security:150-_____ Form 990_EZ, Part II,Line 24,Other-Assets:-OTHER-ASSETS:Beginning of year:_1,000,End of______ -_--___ -_ _ -Year;100 - ----- - - Form 990_EZ,Part li, Line 26,Liabilities:PAYROLL LIABILITIES:Beginning ofyear._4,363,End of Year:_5,680 --------------------------------------------------_.._ _------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------._----------------------------------------------------------------------_-------------- For Paperwork Reduction Act Notice,see the Instructions for Form 990 or 990-EZ. Schedule O(Form 990 or 990-EZ)(2019) HTA Schedule O(Form 990 or 990-EZ)(2019) pane 2 Name of tho organlzallon Employer identification number DHWANI ACADEMY OF PERCUSSION MUSIC --------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------_------------------------------------------------------------------------------------------------------------ -------------------------------------.__---------------------------------------_._.._-----__----------------------------------_----------------- -------------------------------------------------------------------------------------------------------------------------------------------- ____________________________________________________________________________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------ ----___--„„--_„„_-_____ _ _____________________..----___________________________________----.,___________________________.._________-________------______________________ II " _______________________________________________________________..----,._..___-____________________-____________________-----___________________ i ________________________________ - __________________________________..___--______ _______________________________________»_--___ - ' .----_..___________________ _ _ .._--------.-____________________ _ . __..____....____..__________________________________________________________________________________________..____-----_------___________________ _______________________________________ - __________________________________________ - ___________________________.,_„.____________________-_______________________-----___________________________________________---_____________-_ . ____________________________________________________________________________________________________________________________________________ ____________________________..______________________-_____________________-_--_---______________________-_________________-..___________-___-_ _______________________________.._____________________________________________---„-.,__---___________________--_________________-_____________ ____________________________________________________________________________________________________________________________________________ -------------------------------------------------------------------------------------------------------------------------------------------- __________________________________.._____________________________________________-----__-____________________--_______________-.._____________ -------------------------------------------------------------------------------------------------------------------------------------------- Schedule 0(Form 990 or 990-EZ)(2019) TAXABLE YEAR California Exempt Organization ■ FORM 2019 Annual information Return 199 Calendar Year 2019 or fiscal year beginning(mmlddlyyyy) and ending(mmlddlyyyy) Corporadonlorganlzation name California corporation number DHWANI ACADEMY OF PERCUSSION MUSIC Addillonal Information.See Instructions. FEIN addressStreet PMB no. City State Zip code CORONA CA 92882-4741 Foreign country name celstatelcounty Foreign postal code A First Return................................... Yes X❑ No J If exempt under R&TC Section 23701d,has the organization B Amended Return..............................�� Yes®'No engaged In political activities?Seo'instructions.....+[] Yes X� No C IRC Section 4947(a)(1)trust....:................. Yes® No K is the organization exempt under R&TC Section 23701g?.....+[] Yes X� No D Final Information Return? If"Yes,"enter the gross receipts from nonmember sources..—$ +Q Dissolved Surrendered(Withdrawn) MergedlReorganized L If organization is a public charity exempt under R&TC Section Enter date:(mmlddlyyyy) 23701 d and meets the filing fee exception,check box. E Check accounting method: (1)© Cash (2) ❑ Accrual (3) ❑Other No filing fee is required.,....................... F Federal return filed? (1)1011 990T (2)`[]990PF (3)-[]Sch H(990) M Is the organization a Limited Liability Company?....+� Yes No (4)0 Other 990 series N Did the organization file Form 100 or Form 109 to G Is this a group filing?See instructions..............![] Yes❑X No report taxable income?........................�� Yes❑X No H Is this organization in a group exemption............ Yes© No O Is the organization under audit by the IRS or has the If"Yes;'what is the parent's name? IRS audited in a prior year?...........1——.....[] Yes❑X No P Is federal 311024 pending? ............. Yes No Did the organization have any changes to its guidelines Date filed with IRS not reported to the FT137 See instructions............ Yes❑X No Part I Complete Part I unless not required to file this form.See General Information B and C. 1 Gross sales or receipts from other sources.From Side 2,Part II,line 8 ................——4b 1 78,366 00 2 Gross dues and assessments from members and affiliates ........................:....� 2 00 3 Gross contributions,gifts,grants,and similar amounts received...........................10 3 73,950 00 Receipts 4 Total gross receipts for filing requirement test.Add line 1 through line 3.and 9 P 9 q 9 Revenues This line must be completed.If the result is less than$50,000,see General Information S.... 4 1 152,316 00 5 Cost of goods sold .................. F a ` ` AMR 6 Cost or other basis,and sales expenses of assets sold ... 1 61 11)0a, � 7 Total costs.Add line 5 and line 6 ...................................... 7 00 B Total gross income.Subtract line 7 from line 4......................................—' 8 152,316 00 Expenses 9 Total expenses and disbursements.From Side 2,Part II,line 18 .........................T 9 139 862 00 1D Excess of receipts over expenses and disbursements.Subtract line 9 from line 8 ..........:,r 10 12,454 00 11 Total payments.................................................................* 11 00 I 12 Use tax.See General Information K................................................0 12 00 13 Payments balance.If line 11 is more than line 12,subtract line 12 from line 11 ...............0 13 00 1 Filing Fee 14 Use lax balance.If line 12 is more than line 11,subtract line 11 from line 12.................0 14 00 15 Filing fee$10 or$25,See General Information F ...................................... 15 10 00 li 16 Penalties and Interest.See General Information J ................e.......... ......... 16 00 17 Balance due.Add line 12,line 15 and line 16.Then subtract line 11 from the result.......,.Qi 171 10100 Under penalties of pedury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and Sign belief,It Is true,correct,and oomplele.Declaration of preparer(other than taxpayer)Is based on all Information of which preparer has any knowledge. Here Signature F e Dale - Telephone ofofFlcer IIT/14/2018 Preparer's Date Check If self- © — PTIN signsture `SUBHRA K BANERJEE 07/20/2020 employed Paid " irm's FEIN. Preparer's . Firm's name(or yours, S & A ASSOCIATES C PA r S Use Only Ifself-employed) and address - Tele hone IOS ANGELES, CA 90071 May the FTB discuss this return with the preparer shown above?Soo instructions...................• ❑Yes No Form 199 2019 Side 1 DHWANI ACADEMY OF PERCUSSION MUSIC OWN Part II Organizations with gross receipts of more than$50,000 and private foundations regardless of amount of gross receipts--complete Part II or furnish substitute information. 1 Gross sales or receipts from all business activities.See instructions.............................."' 1 78,366 00 2 Interest ....................... ..................." 2 00 Receipts3 Dividends ............................................................................ 3 00 from 4 Gross rents ........................................................................... 4 00 Other5 Gross royalties ......................................................................." 5 00 Sources 6 Gross amount received from sale of assets(See Instructions) .................... 6 00 7 Other income.Attach schedule ..........................................................op 7 00 8 Total gross sales or receipts from other sources.Add line 1 through line 7.Enter here and on Side 1,Part I,line 1..........,, 8 78,366 00 9 Contributions,gifts,grants,and similar amounts paid.Attach schedule ............................0 9 00 10 Disbursements to or for members.........................................................r 10 00 11 Compensation of officers,directors,and trustees.Attach schedule .............................." 11 00 12 Other salaries and wages ............................................................... 121 52,869 00 Expenses13 Interest .............................................................................." 13 00 and 14 Taxes .............................. 14 00 15 Rents ............... I Disburse- .............................. ...............� 15 15,946 00 , manta 16 Depreciation and depletion(See Instructions) ................................ ................ 16 00 ! 17 Other Expenses and Disbursements.Attach schedule ........................................• 17 71,045 00 18 Total expenses and disbursements.Add line 9 through line 17.Enter here and on Side 1,Part I line 9,... 18 .139,862 00 Schedule L Balance Sheet Be innin of taxable vear End of taxable year Assets a b c d 1 Cash n 1 's 23,026s> .. 37,697 2 Net accounts receivable >, 4�. _a " � "; fi.t,';a10 3 Not notes receivable ....................... fMN 4 Inventories .... ° 5 Federal and state government obligations ...... 6 Investments in other bonds .................. NO'�a., � �'k�. .a fw.R,, . 7 Investments In stock \ �e v, x s s y�4 L'R b: 1 8 Mortgage loans....................... , ;. k� i °' :.. � i�FeQ'� t 3�3', • 9 Other investments.Attach schedule .......,.,. ;� y��.� a��.,�x�, �,, f„� �a`t,,,x,�„� 10 a Depreciable assets - b Less accumulated depreciation ........... 11 Land ................................... 12 Other assets.Attach schedule ......:........ ° " $4 100 24 13 Total assets ........................ � �� s F s � r� ke 026 � c rr �� 37,797 Liabilities and net worth w'13 .° �x 14 Accounts payable 15 Contributions,gifts,or grants payable .... � � at • 16 Bonds and notes payable ............. , P 17 Mortgages payable 18 Other liabilities.Attach schedule ....... "0, 4,363 a � aF,3 ,r zt 5,680 j ......... karts r v � �� R2rx 19 Capital stock or principal fund ..... - Via, �e 20 Paid-in or capital surplus.Attach reconciliations �dui y x - ""`,.3 a5a�`av ea g '�E'+,a.v:� • 21 Retained earnings or income fund .....,. r��c ,.� h a,W"'N ar � 19,663 ._, 32,117 22 Total liabilities and net worth ��;,3� p�, "�, 4 ', 24,026 R0, �i; 37,797 Schedule M-1 Reconciliation of income per books with income per return Do not complete this schedule If the amount on Schedule L,line 13,column(d),is less than$50,000 1 Net income per books ........,., 7 Income recorded on hooks this year 2 Federal Income tax ........................ + not Included in this return.Attach schedule 3 Excess of copilot losses over capital gains + 0 Reductions In this return not charged 4 Income not recorded on hocks this year. �,} `�?�` , „�,,��;.�_ against hook income this year. Attach schedule ....... Attach schedule..................... • 5 Expenses recorded on books this year not 9 Total.Add line 7 and line 8 ........... deducted in this return.Attach schedule ....... 10 Net income per return. I 6 Total.Add line 1 through line 5.........:.:.... Subtract line 9 from line 6............. Side 2 Form 199 2019 r— STATE OF CALIFORNIA DEPARTMENT OF JUSTICE RRF•1 PAGE 1 of 5 (Rev.0912017) MAILTO: ANNUAL REGISTRATION RENEWAL PEE REPORT (For Registry Use Only) Palsg oBf CharitOU47a6leTrusts TO ATTORNEY GENERAL OF CALIFORNIA Sacramento,CA94203-4470 Sections 12586 and 12587,California Government Code STREETADDRESS: - 1300I Street 11 Cal.Code Rags.sections 301306,309,311,and 312 Sacramento,CA 95814 Failure to submit this report annually no later than four months and fifteen days after the end of the (916)21D-6400 organization's accounting period may result In the loss of tax exemption and the assessment of a wEESITE ADDRESS: minimum tax of$800,plus interest,and/or fines or filing penalties,Revenue&Taxation Code section W".caa.ca.00vlcharitles 23703;Government Code section 12586.1.IRS extensions will be honored. DHWANI ACADEMY OF PERCUSSION MUSIC Check if: Name of organization ❑ Change of address List all DBAs and names the organization uses or has used ❑ Amended report k Addiross um er and Street) State Charity Registration Number I Corona CA 92882-4741 City or Town,Slate,and ZIP Code Corporation or Organization No. �i Tole hone Num er - E-mail Address Federal Employer I.D.No. ANNUAL REGISTRATION RENEWAL FEE SCHEDULE(11 Cal.Code Rags.sections 301307,311,and 312) Make Chock Payable to Department of Justice Gross Annual Revenue Fee Gross Annual Revenue Fee Gross Annual Revenue Fee Less than$25,000 0 Between$100,001 and$250,000 $50 Between$1,000,001 and$10 million $150 Between$25,000 and$100,000 $25 Between$250,001 and$1 million $75 Between$10,000,001 and$50 million $225 Greater than$50 million $300 PART A-ACTIVITIES For your most recent full accounting period(beginning 1/1/2019 ending 12/31/2019 )list: Gross Annual Revenue$ 152,316 Noncash Contributions$ 0 -Total Assets$ 37,797 Program Expenses$ Total Expenses$_'. 0 PART B-STATEMENTS REGARDING ORGANIZATION DURING THE PERIOD OF THIS REPORT Note: All questions must be answered.If you answer"yes"to any of the questions below,you must attach a separate page providing an explanation and details for each"yes"response.Please review RRF-1 instructions for Information required. Yes No ' 1. During this reporting period,were there any contracts,loans,leases or other financial transactions between the organization and any officer,director or trustee thereof,either directly or with an entity In which any such officer,director or trustee had any financial interest? 2. During this reporting por)od,was there any theft,embezzlement,diversion or misuse of the organization's charitable property or funds? 3. During this reporting period,were any organization funds used to pay any penalty,fine or judgment? 4. During this reporting period,were the services of a commercial fundraiser,fundraising counsel for charitable purposes,or commercial i coventurer used? 5. During this reporting period,did the organization receive any governmental funding? # 6. During this reporting period,did the organization hold.a raffle for charitable purposes? 7. Does the organization conduct a vehicle donation program? 8. Did the organization conduct an independent audit and prepare audited financial statements in accordance with generally accepted accounting principles for this reporting period? 9. At the and of this reporting period,did the organization hold restricted net assets,while reporting negative unrestricted net assets? 1 declare under penalty of perjury that I have examined this report,including accompanying documents,and to the best of my knowledge and belief,the content Is true,correct and complete. 1 111 4/20 1 8 Signature of Authorized Agent Printed Name Title Date DICg C{O to �R� CRY s� sEcaE� oli � (Of aNw�i�� Gym ��et Aad�ss P� � �N1J'►�g(N� 2 g�pT\P�"KA� 3 ces��d' mac'odiot a DHWANI ACADEMY OF PERCUSSION MUSIC Line 17, Part II I;CA 199) - Other Deductions 1 Pension plans,employee benefits. . . . .. . . 1 0 2 Legal fees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 0 3 Accounting fees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 0 4 Other professional fees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 34,144 5 Travel,conferences,and meetings. . . . . . . . . . . . . . . . . . . . . . . . . . . s 0 6 Printing and publlcatlons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 232 7 Special events direct expenses. . . . . . . . . , . . . . . . . . . . . . . . . . . . 7 0 8 Office expenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a 0 9 Other expenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 36,669 10 11 T_� 12 Total 12 71,045 I Line 12 Sch L CA 199 -Other Assets I Beginning End i 1 Assets 1 1,000 100 j 2 2 3 �. 3 4 4 8 a 9 9 10 1 000 100 10 Total Line 18, Sch L CA 199 - Other Liabilities Beginning End of of Year Year 1 LiabllitleS w _ ——— ��--� 1 4,363 5,680 2 - 2 3 _ _ _ _ 3 4 4 5 6 B _ _ —� 8 9 10 Total 10 4,363 5,680 l j { ®2020 Universal Tax Systems Inc.andfor its atliliates and licensors.Al Fights reserved, Short Form OMallo.1545-0047 Farm 990-EZ Return of Organization Exempt From Income Tax �0,� 9 Under section 501(c),527,or 4947(a)(1)of the Internal Revenue Code(except private foundations) ► Do not enter social security numbers on this form,as It may be made public. • ' Inepartment(ifthe ternal Revenue Treasury Go to wwwJrs.uoWForm990.E.Zfor instructions and the latest information. • ' • A For the 2019 calendar year,or tax year beginning ,and ending B Check If applicable: C Name of organizatlon D Employer identification number ❑ Address change DHWANI ACADEMY OF PERCUSSION MUSIC ❑ Name change Number and street(or P.O.box if mail is not delivered to street address)' Room/suite ❑ Initial return E Telephone number ❑ Final retumlfarminated Cityor tcFwn State ZIP.code Amended return Corona CA 92882-4741 Application pending Foreign country name Foreign provincelstatelcounty Foreign postal code F Group Exemption Number► 0000 G Accounting Method: 0 Cash ❑Accrual Other(specify) 10' H Check►❑ If the organization Is I Website: ► NIA not required to attach Schedule B J Tax-exempt status(chock only one)— E1501(c)(3) E1501(c)( )t (insert no.)F-1 4947(a)(1)or 1:1527 (Form 990,990-EZ,or 990-PF). K Form of organization: ❑X Corporation Trust 0 Association Other t- Add lines 5b,6c,and 7b to line 9 to determine gross receipts.If gross receipts are$200,000 or more,or If total assets Part II,column B are$500,000 or more,file Form 990 instead of Form 990-EZ . t► $ 152,316 Revenue,Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part 1) Check if the organization used Schedule O to respond to any question in this Part I . . . . . . . �X 1 Contributions,gifts,grants,and similar amounts received. . . . . . . . . . . . . . . . . 1 73,950 2 Program service revenue including government fees and contracts. . . . . . . . . . . . . 2 78,366 3 Membership dues and assessments. . . . . . . . . . . . . . . . . . . . . . . 3 4 Investment income. . . . . . . . . . . . . . . . . . . . . . . . . . . 4 5a Gross amount from sale of assets other than Inventory. 5a F R° b Less:cost or other basis and sales expenses. . . . . . . . . . 5b c Gain or(loss)from sale of assets other than inventory(subtract line 5b from line 5a). . . . . . 5c 0 8 Gaming and fundraising events: a Gross income from gaming(attach Schedule G if greater thantR4ya $15,000) . . . . . . . . . . . . . . . . . . 6a � ` c b Gross income from fundraising events(not including $ of contributions rr from fundraising events reported on I€ne 1)(attach Schedule G if the xM sum of such gross income and contributions exceeds$15,000). . 6b c Less:direct expenses from gaming and fundra€sing events.. 6c d Net Income or(loss)from gaming and fundraising events(add lines 6a and 6b and subtract ' line 6c) . . . . . . . . . . . . . . . . . . . . . . . . 6d 0 7a Gross sales of inventory,less returns and allowances. . . . . . 7a b Less:cost of goods sold. . . . . . . . . . . . . . 7b c Gross profit or(loss)from sales of inventory(subtract line 7b from line 7a). . . . . . . . . 7c 0 8 Other revenue(describe in Schedule 0). . . . . . . . . . . . . . . . . . . . . . 8 9 Total revenue.Add lines 1,2,3,4,5c,6d,7c,and 8. . .No- 9 152,316. 10 Grants and similar amounts paid(list in Schedule 0). . . . . . . . . . . 10 11 Benefits paid to or for members. . . . . . . . . . . . . . . . . . . . . . . . . 11 y 12 Salaries,other compensation,and employee benefits. . . . . . . . . . . . . . . . 12 52,869 13. Professional fees and other payments to independent contractors . . . . . . . . . 13 34,144 ri14 Occupancy,rent,utilities,and maintenance. . . . . . . . . . . . . . . . . . . . . . . 14 15,948 uu 15 Printing,publications,postage,and shipping . . . . . . . . . . . . . . . . . . . 15 232 16 Other expenses(describe in Schedule O) . . . . . . . . . . . . . . . . . . . . . . . 16 36,669 17 Total expenses.Add lines 10 through 16. ► 17 139,862 . . . . . . . . . . . . . . . . . . . . . 18 Excess or(deficit)for the year(subtract line.17 from line 9).. . . . . . . . . . . . . . 18 12,454 19 Net assets or fund balances at beginning of year from line 27,column A must agree with rn g� g Y ( ( })( 9 end-of-year figure reported on prior year's return). . . . . . . . . . . . . . . . . . . . 19 19,663 x20 Other changes in net assets or fund balances(explain in Schedule O) . . . . . . . . . . 20 21 Net assets or fund balances at end of year.Combine lines 18 through 20 . e 21 32,117 For Paperwork Reduction Act Notice,see the separate Instructions. Form 990-EZ(2ol9) HTA Form 990-Ez(2010) DHWANI ACADEMY OF PERCUSSION MUSIC Pane 2 LM Balance Sheets (seethe instructions for Part 11) Check If the organization used Schedule O to respond to any question In this Part II. . . . . . . . • . . . . . . . . . �X (A) Beginning of year (B) End of year 22 Cash,savings,and investments . . . . . . . . . . . . . . . . . . . . . . • 23,026 22 37,697 23 Land and buildings. . . . . . . . . . . . . . . . . . . . . . . . . . . 23 24 Other assets(describe in Schedule O). . . . . . . . . . . . . . . . • . . . 1,600 24 100 25 Total assets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24,026 25 .373797 26 Total liabilities(describe in Schedule 0). . . . . . . . . . . . . . . . . . 4,363 26 5 680 27 Net assets or fund balances line 27 of column B must a ree with line 21 . . 19 663 27 32,117 Statement of Program Service Accomplishments(see the Instructions for Part III) Check if the organization used Schedule 0 to respond to any question in this Part III. . . . . . . ❑ Expenses What is the organization's.primary exempt purpose? TO PROMOTE INDIAN CLASSICAL MUSIC AND CULTURE (Required for section 501(c)(3)and 501(c)(4) Describe the organization's program service accomplishments for each of Its three largest program services, organizations;optional as measured by expenses.In a clear and concise manner,describe the services provided,the number of for others.} arsons benefited and other relevant information for each program title. 28 THE ORGANIZATION ORGANIZED AND PROMOTED VARIOUS CONCERTS ON INDIAN CLASSICAL MUSIC DURING THE YEAR.THE ORGANIZATION PROVIDED LESSONS ON LEARNING INDIAN - -- - ----- - -- --- ---------------------...__----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - -- PERCUSSION-MUSIC Grants$ If this amount Includes foreign grants,check here. ► 48a 29 ---------------------------------------------------------------------------------------------------------------------_- ----------------------- ------- --__----------------- ----------------------------------------------_--------- 1 (Grants$ ) If this amount includes foreign grants,check here. to- El 29a 30 ------------------------------------------. _--------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------- --------------------- --------------------------------------------------------------------_------------------------- (Grants$ } If this amount includes foreign grants,check here. . . . . . . ► 0 30a 31 Other program services(describe in Schedule 0). . . . . . . . . . . . . . . . . . . . . . . (Grants$ ) If this amount Includes foreign grants,check here. . . . . ► ❑ 31a 32 Total program service expenses. add lines 28a through 31a . ► 32 0 List of Officers,Directors,Trustees,and Key Employees(list each one even if not compensated—see the instructions for Part IV) Check if the organization used Schedule O to respond to any question in this Part IV. . . . . . . . . . ❑ W Reportable (d)Health benefils, (b) Average compensation oontribulionsto (a)Estimated amount of (a)Name and title hours per week (Forms W-2I1099-MISC) employee benefit p l other cam ensadon devoted to poalgon p Yee p (ff not paid,enter-0-) and deforred compensatlon � ABHIJIT BANERJEE PRESIDENT HrIWK 4.00 j BALDEV JHITA -- - - ---- ----------------------- ------------------------ TREASURER HrIWK 2.00 JYOTIPRAKAS MISTRI SECRETARY HrIWK 32.00 _ ------------------ HrIWK ---__----- HrI4VK - ------------ HrIWK --------------------------------------------------- »..______ HHWK ---_--__-- HAWK --------------------------------------------------------- -- HrMK ------------------------------------------------------------ HOW ------------------------..__ __-_- Hr1WK - __- HrIWK Form 990-EZ pof 9) Form 990-rz(2019) DHWANI ACADEMY OF PERCUSSION MUSIC Pa e 3 Other Information (Note the Schedule A and personal benefit contract statement requirements in the instructions for Part V.)Check if the organization used Schedule 0 to respond to any question in this Part V. [] Yes No 33 Did the organization engage in any significant activity not previously reported to the IRS?If"Yes,"provide a detailed description of each activity In Schedule O. . . . . . . . . . . . . . . . . . . . . . . 33 X 34 Were any significant changes made to the organizing or governing documents?If"Yes," attach a conformed copy of the amended documents if they reflect a change to the organization's name.Otherwise,explain the change on Schedule 0.See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 X 35 a Did the organization have unrelated business gross income of$1,000 or more during the year from business activities(such as those reported on lines 2,62,and 7a,among others)?. . . . . . . . . . . . . . . 35a X b If"Yes"to line 35a,has the organization fled a Form 990-T for the year9 If"No,"provide an explanation in Schedule 0. 35b c Was the organization a section 501(c)(4),501(c)(5),or 501(c)(6)organization subject to section 6033(e)notice, reporting,and proxy tax requirements during the year?If"Yes,"complete Schedule C,Part III . 35c X 36 Did the organization undergo a liquidation,dissolution,termination,or significant disposition of net assets during the year?If"Yes," complete applicable parts of Schedule N.. . . . . . . . . . . . . . . . 36 X 37 a Enter amount of political expenditures,direct or indirect,as described In the instructions. ►I 37a M.,>M b Did the organization file Form 1120-POL for this year?. . . . . , . . . . . . . . . . . . . . . . 37b I I X 38 a Did the organization borrow from,or make an loans to,an officer,director,trustee,or key employee;or were r9 Y Y Y any such loans made in a prior year and still outstanding at the and of the tax year covered by this return?. . . . 38a X b If"Yes,"complete Schedule L,Part Il.and enter the total amount involved. 38b k: 23i 39 Section 501(c)(7)organizations. Enter:. a Initiation fees and capital contributions included on line 9. . . . . . . . . 39a a k b Gross receipts,included on line 9,for public use of club facilities. . . . . 39b 40 a Section 501(c)(3)organizations.Enter amount of tax imposed on the organization during the year under: SFs; r`k section 4911 ► ;section 4912 ► ;section 4955 ► b Section 501 c 3,501 c 4 ,and 501 c 29 organizations.Did the organization engage In any section 4958 excess benefit transaction during the year,or did it engage in an excess benefit transaction in a prior year i that has not been reported on any of its prior Forms 990 or 990-EZ?If"Yes,"complete Schedule L,Part I. , . . 40b X c Section 501(c)(3),501(c)(4),and 501(c)(29)organizations.Enter amount of tax imposed tjk. t Y �" on.organization managers or disqualified persons during the year under sections 4912, Y ' � 3 v 4955,and 4958. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ► ,. , v g ski d Section 501(c)(3),501(c)(4),and 501(c)(29)organizations.Enter amount of tax on line 40c reimbursed by the organization. . . . . . . . . . . . . . . . ► e All organizations.At any time during the tax year,was the organization a party to a prohibited tax shelter transaction?If"Yes,"complete Form 8886-T.. . . . . . . . . . . . . . . . . . . . . . 40e X ' 41 List the states with which a copy of this return is filed. IN. 42 a The organization's books are in care of ► JYOTIPRAI{ASH MISTRI _ Telephone no. 0- Located at ► City CORONA ST__CA zIP+4 ► 92882 ..... -- 882------------------ b At any time during the calendar year,did the organization have an interest in or a signature or other authority over Yes No a financial account in a foreign country(such as a bank account,securities account,or other financial account)? 42b X If"Yes,"enter the name of the foreign country 11, See the Instructions for exceptions and filing requirements for FinCEN Form 114,Report of Foreign Bank and u. P 9 q P 9 Financial Accounts(FBAR), a . c At any time during the calendar year,did the organization maintain an office outside the United States? . . . . 42c X If"Yes,"enter the name of the foreign country ► 43 Section 4947(a)(1)nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041—Check here. . . . . . . . . . ►❑ and enter the amount of tax-exempt interest received or accrued during the tax year. . . . . . . . 111-1 43 Yes No 44 a Did the organization maintain any donor advised funds during the year?If"Yes,"Form 990 must be - completed instead of Form 990-EZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44a X b Did the organization operate one or more hospital facilities during the year?If"Yes,"Form 990 must be '• � ` z completed instead of Form 990-EZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44b X c Did the organization receive any payments for indoor tanning services during the year? . . . . . . . . . . 44c X d If"Yes"to line 44c,has the organization filed a Form 720 to report these payments?If"No,"provide an . L.F explanation in Schedule O. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44d X 45 a Did the organization have a controlled entity within the meaning of section 512(b)(13)?. . . . . . . . . . . . 45a X b Did the organization receive any payment from or engage in any transaction with a controlled entity within the 0FK meaning of section 512(b)(13)?If"Yes,"Form 990 and Schedule R may need to be completed instead of , 5`u ; Form 990-EZ.See instructions. 45b X Form 990-EZ(2019) Form 990-Ez(2019) DHWANI ACADEMY OF PERCUSSION MUSIC Pone 4 Yes No 46 Did the organization engage,directly or indirectly,in political campaign activities on behalf of or in opposition to candidates for public office?If"Yes,"complete Schedule C,Part 1. . 46 X JIM Section 501(c)(3)Organizations Only All section 501(c)(3)organizations must answer questions 47-49b and 52,and complete the tables for lines 50 and 51. Check if the organization used Schedule O to respond to any question in this Part VI . . . . . . . . . . Yes No . 47 Did the organization engage In lobbying activities or have a section 501(h)election in effect during the tax year?If"Yes,"complete Schedule C,Part 11. . . . . . . . . . . . . . . . . , . . . , . . . . . . 47 X 48 Is the organization a school as described In section 170(b)(1)(A)(11)?If"Yes,"complete Schedule E. , . . . . . . . 48 X 49 a Did the organization make any transfers to an exempt non-charitable related organization?. . . . . . . . . . . . 49a X b If"Yes,"was the related organization a section 527 organization?.. . . . . . . . . . . . . . . . . . . . . . 49b 50 Complete this table for the organization's five highest compensated employees(other than officers,directors,trustees,and key employees)who each received more than$100,000 of.com ensatlon from the organization.If there is none,enter"None." (b)Average (e)Reportable (d)Health benefits, contributions to employee (o)Estimated amoun (a)Name and title of each employee hours per week, compensation t of - •i devoted to position (Forms W-211099-MI3C) benefit plans,and deferred other compensation compensation - -a- Nme None ----------------------------------------------------- Title HrWK .00 Name ---- - - - ---- -- ---- --- --- - -------------------- Me HrA'VK '00 Name Title HrMK .00 --------------------------------------------------- Name Title Hr1WK .00 --------------------------------------------------- Name Title Hr/WK .00 f Total number of other employees paid over$100,000. . . . . . . . ► 51 Complete this table for the organization's five highest compensated independent contractors who each received more than $100,000.of compensation from the organization.If there Is hone,enter"None." (a)Name and business address of each independent contractor (b)Type of service (c)Compensation None St.. r __Name----_ -.__. --_--._..--------------�-�-_---------------------------------------- City ST ZIP Name Str ci ST ZIP Name --Str --- ----------------------------------------- - ---------------------------------- city ST ZIP Name Str ----------------------------------------------------- __--- _.._---------------- CI ST zip Name Str CI ST ZIP d Total number of other independent contractors each receiving over$100,000. . . . . . . 52 Did the organization complete Schedule A?Note:All section 501(c)(3)organizations must attach a completed Schedule A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ►[]X Yes No Under penalties of perjury,I declare that I have examined this return,Including accompanying schedules and statements,and to the best or my knowledge and belief,it is true,correct,and complete.Declaration of preparer(other then officer)Is based an all Information of which preparer has any knowledge. Sign / Signature of officer Date Here ABHIJIT BANERJEE 11/14/2018 Type or print name and title Paid Printlrype preparer's name Preparer's signature Date Chedc [ If PTIN SUBHRA K BANERJEE SUBHRA K BANERJEE 7/20/2020 self-employed, Prt?pa n Firm's name ► S&A ASSOCIATES CPA'S Firm's EIN USt?On ly Firm's address ► ,LOS ANGELES,CA 90071 Phone no. May the IRS discuss this return with the preparer shown above?See instructions. . . . . . . . . . . . . . . . . ►[] Yes No Form 990-EZ(2oig) SCHEDULE A Public CharityStatus and Public Support (Form 980 or 990-EZ} pp Complete if the organization is a section 601(c)(9)organization or a section 4947(a)(1)nonexempt charitable trust. �O 1 9 Department of the Treasury i Attach to Form 990 or Form 990-EZ. • + • + Internal Revenue service ► Go to www.ks!. ay1Form990 for instructions and the latest information. Name of the organization Employer identification number DHWANI ACADEMY OF PERCUSSION MUSIC Reason for public Chari Status All organizations must complete this art. See instructions. The or anization is not a private foundation because it Is:(For lines 1 through 12,check only one box.) 1 A church,convention of churches,or association of churches described in section 170(b)(1)(A)(i). 2 A school described In section 170(b)(1)(A)(11).(Attach Schedule E(Form 990 or 990-EZ).) 3 A hospital or a cooperative hospital service organization described in section 174(b)(1)(A)(iii). 4 A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(111).Enter the . hospital's name,city,and state: 5 An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv).(Complete Part li.) 6 ❑ A federal,state,or local government or governmental unit described in section 170(b)(1)(A)(v). 7 ❑ An organization that normally receives a substantial part of its support from a governmental unit or from the general public described In section 170(b)(1)(A)(vi).(Complete Part ll.) 8 ❑ A community trust described in section 170(b)(1)(A)(vl).(Complete Part Il.) {I 9 ❑ An agricultural research organization described in section 170(b)(1)(A)(ix)operated.in conjunction with a land-grant college or university or a non-land-grant college of agriculture(see instructions). Enter the name,city,and state of the college or university: 10 OX An organization that normally receives:(1)more than 33 113%of Its support,from contributions, membership fees,and gross receipts from activities related to its exempt functions--subject to certain exceptions,and(2)no more than 33 113%of Its support from gross investment income and unrelated business taxable income(less section 611 tax)from businesses acquired by the organization after June 30, 1976.See section 549(a)(2).(Complete Part Ill.) 11 An organization organized and operated exclusively to test for Public safety.See section 549(a)(4). 12 [:]An organization organized.and operated exclusively for the benefit of,to perform the functions of,or to carry out the purposes of one or more publicly supported organizations described in-section 549(a)(1)or section 509(a)(2).See section 509(a)(3). Check the box in lines 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f,and 12g. a Type 1.A supporting organization operated,supervised,or controlled by its supported organization(s),typically by giving the supported organization(s)the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization.You must complete Part IV,Sections A and B. b Type ill.A supporting organization supervised or controlled In connection with its supported organizatlon(s),by having control or management of the supporting organization vested in the same persons that control or manage the supported organizatlon(s).You'must complete Part IV,Sections A and C. c Type III functionally integrated.A supporting organization operated in-connection with,and functionally integrated with, its supported organization(s)(see instructions).You must complete Part 1V,Sections A,D,and E. d Type III non-functionally integrated.A supporting organization operated in connection with its supported organization(s) that Is not functionally integrated.The organization generally must satisfy a distribution requirement and an attentiveness requirement(see instructions).You must complete Part IV,Sections A and D,and Part V. e El Check this box if the organization received a written determination from the IRS that it is a Type I,Type ll,Type III functionally integrated,or Type III non-functionally integrated supporting organization. If Enter the number of supported organizations. . . . . . . . . . . . . . . . . . . . . . . . . . Provide the following information about the supported or anizations. (1)Name of supported organization (11)EIN (ill)Type or organization (W)Is the organization (v)Amount of monetary (vi)Amount of (described on lines 1710 listed in your governing support(see other support(see above(see Instructions)) document? instructions) Instructions) 9 Yes No (A) (B) (G) (o) (E) Total v� ,�°� �a N ¢ �.� p'�e w e r ��e a�,qa, k - For Paperwork Reduction Act Notice,see the Instructions for Form 994 or 990-EZ. Schedule A(Form 990 or 990•EZ)2019 HTA Schedule A(Form 990 or 990-EZ)2019 DHWANI ACADEMY OF PERCUSSION MUSIC Pans 2 NMI Support Schedule for Organizations Described in Sections 170(b)(1)(A)(1v)and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization Fails to qualify under the tests listed below, please complete Part III. Section A. Public Support Calendar year(or fiscal year beginning in) ► a 2015 b 2016 c 2017 d 2018 a 2019 Total 1 Gifts,grants,contributions,and membership fees received.(Do not include any"unusual grants."). . . . . 0 2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf. . . . . . 0 3 The value of services or facilities furnished by a governmental unit to the organization without charge. . . . 0 4 Total.Add lines 1 through 3 . . . . . 0 0 0 0 0 0 5 The portion of total contributions b p y each person(other than a governmental unit or publicly i P k *c t C x 9 P Y supported organization)Included on ;'�x �'�'a a � � ry�� v+ ,ti'��Y F•�� `��` �� ; - line I that exceeds 2%of the amount shown on line 11,column(f). � :t ) 4t a tt F\ a\ : ;; �.<e�. .,k1 zw41 . 4 F r s. 6 Publle support.Subtract line 6 from line 4 �;`�w.,.�.� `k� ,� .� '��s�x�� , ��Est r�.��..:,�� R��,��„- 0 Section B.Total Support Calendar year(or fiscal year beginning in) ► a 2015 b 2016 c 2017 d 2018 a 2019 Total 7 Amounts from.line 4. . . . . . 0 0 0 0 0 0 8 Gross Income from interest,dividends, payments received on securities loans, rents,royalties,and income from similar sources. . . . . . . . . . 0 9 Net income from unrelated business activities,whether or not the business is regularly carried on. . . . . . . . . 0 10 Other Income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.). . . . . . . . 0 v1 kv� e k $°vim\ d ^ n aac @2 F c\ a 't �•': 11 Total support.Add Tines 7 through 10 12 Gross receipts from related activities,etc.(see Instructions). . . . . . . . . . . . . . . . . . . 12 13 First five years.If the Form 990 is for the organization's first,second,third,fourth,or fifth tax year as a section 501(c)(3) organization,check this box and stop here. . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . , . . .► 1 Section C.Computation of Public Support Percentage 14 Public support percentage for 2019(line 6,column(1)divided by line 11,column(0). . . . . . . . . . . 14 0.00% 15 Public support percentage from 2018 Schedule A,Part II,line 14. . . . . . . . . . . . . . . 15 0,00% 16a 33 113%support test-2019.If the organization did not check the box on line 13,and line 14 is 33 113%or more,check this box and stop here.The organization qualifies as a publicly supported organization. . . . . . . . . . . . . . . . . . . . . . . . . . . . .0-0 b 33 113%support test 2018.If the organization did not check a box on line 13 or 16a,and line 15 is 33 113%or more,check this box and stop here.The organization qualifies as a publicly supported organization. . . . . . . . . . . . . . . . . . ►❑ 17a 10%-facts-and-circumstances test-2019.If the organization did not check a box on line 13,16a,or 16b,and line 14 10%or more,and if the organization meets the"facts-and-circumstances"test,check this box and stop here.Explain in Part VI how the organization meets the"fads-and-circumstances"test.The organization qualifies as a publicly supported organization.. . . . . . . . . . . . . .. . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ►❑ b 10%-facts-and-circumstances test-2018.If the organization did not check a box on line 13,16a,16b,or 17a,and line 15 is 10%or more,and if the organization meets the"facts-and-circumstances"test,check this box and stop here. Explain In Part VI how the organization meets the'facts-and-circumstances"test.The organization qualifies as a publicly supported organization. . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . ►❑ 18 Private foundation.If the organization did not check a box on line 13,16a,16b,17a,or 17b,check this box and see instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ►❑ Schedule A(Form 990 or 990-EZ)2019 Schedule A(Form 990 or 990-Ez)2019 DHWANI ACADEMY OF PERCUSSION MUSIC M Page 3 ROM Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part IL If the organization fails to qualify under the tests listed below, please complete Part ll. Section A.Public Support Calendar year(or fiscal year beginning In) ► a 2015 b 2018 c 2017 d 2018 a 2019 Total 1 Gifts,grants,contributions,and membership fees received.(Do not include any"unusual grants.") 12,400 10,000 10,000 10,000 73,950 116,350 2 Gross recelpte from admissions,merchandise sold or services performed,or facilities furnlshed in any activity that is related to the orgenizeticn'stax-exempt purpose. . . 95,344 101,911 112177 99,74D 78,366 487,538 3 Gross recelpts from eutivilies that are not an unrelated trade or business under section 513. 0 { 4 Tax revenues levied for the organizatton's benefit and either paid to or expended on Its behalf. . . . . . . 0 ? 5 The value of services or facilities l furnished by a governmental unit to the organization without charge. 0 I -6 Total.Add lines 1 through 5. . . . . 107,744 111,911 122,177 109,740 152,3161 603,888 I 7a Amounts included on lines 1,2,and 3 received from disquallfled persons. 0 b Amounts included on lines 2 and 3 i received from other than disqualified persons that exceed the greater of$5,000 or 1%of the amount on line 13 for the year. . . 0 c Add lines 7a and 7b. . . . . . . . . 0 0 0 0 0 0 8 Public support(Subtract line 7c from 603,888. line 6.). . . . . . .., ' Section D.Total Suipport Calendar year(or fiscal year beginning in) ► a 2015 b 2016 c 2017 d 2018 a 2019 Total 9 Amounts from line 6. . . . . . . . . 107,744 111,911 122,177 109 740 152,316 603,888 10a Gross income from Interest,dividends, • I payments received on securltles loans,rents, royalties,and Income from similar sources. . . 0 b Unrelated business taxable income(less . section 511 taxes)from businesses acquired after June 30,1975 . . . . . 0 1 c Add lines 10a and 10b. . . . . . . . 0 0 0 0 0 0 11 Net income from unrelated business activities not Included in tine 10b,whether or not the business is regularly carried on. 0 12 Other income.Do not Include gain or loss from the sale of capital assets (Explain In Part VI.). . . . . . . . 0 13 Total support.(Add lines 9,10c,11, and 12.). . . . . . . . . . . . . . 107,744 1 111,9111 122,1771 109,7401 152,316 603,888 14 First five years.If the Form 990 is for the organization's first,second,third,fourth,or fifth tax year as a section 501(c)(3) organization,check this box and stop here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .► ❑ Section C.Computation of Public Support Percentage 15 Public support percentage for 2019(line 8,column(f),divided byline 13,column(f)). . . . . . 15 100.00% 16 Public support percentage from 2018 Schedule A,Part ill,line 15. 16 100.00% Section D.Computation of Investment Income Percentage 17 Investment income percentage for 2019(line 10c,column(f),divided by line 13,column(f)), . . . . . 17 0.00% 18 Investment income percentage from 2018 Schedule A,Parr 111,line 17. . . . . . . . . . . . . . . . . 18 . 0.00% 19a 33 113%support tests--2019.If the organization did not check the box on line 14,and line 15 Is more than 331I3%,and line 17 is not more than.33 113%,check this box and stop here.The organization qualifies as a publicly supported organization. . . . . . . . . . . . . ► X❑ b 33113%support tests--2018.If the organization did not check a box on line 14 or line 19a,and line 16 is more than 33 113%,and line 1.8 is not more than 33 113%,check this box and stop here.The organization qualifies as a publicly supported organization, . . . . . . . . ► ❑ 20 Private foundation.If the organization did not check a box on line 14,19a,or 19b,check this box and see Instructions. . ... . . . . . . . . .► ❑ Schedule A(Form 990 or 990-EZ)2019 Schedule A(Form 990at990-EZ)2019 DHWANI ACADEMY OF PERCUSSION MUSIC Page Supporting Organizations (Complete only if you checked a box in line 12 on Part I. If you checked 12a of Part I,complete Sections A and B. If you checked 12b of Part I,complete Sections A and C. If you checked 12c of Part I, complete _ Sections A, D,and E. If you checked 12d of Part I, complete Sections A and D,,and complete Part V.) Section A.All Supporting Organizations Yes No 1 Arp all of the organization's supported organizations listed by name in the organization's governing documents?If'No,"describe in Part Whow'the supported organizations are designated.If designated by 1r Y.i"s class or purpose,describe the designation.If historic and continuing relationship,explain. 1 2 . Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1)or(2)?If"Yes,"explain in Part W how the organization determined that the supported organization was described In section 509(a)(1)or(2). 2 3a Did the organization have a supported organization described in section 501(c)(4),(5),or(6)?If"Yes,"answer (b)and(c)below. 3a b Did the organization confirm that each supported organization qualified under section 501(c)(4),(5),or(6)and satisfied the public support tests under section 509(a)(2)?1f"Yes, describe in Parl Vl when and how the organization made the determination. 3b c Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2) y " (B)purposes?If"Yes,"explain in Part W what controls the organization put in place to ensure such use. 3c 4a Was any supported organization not organized in the United States("foreign supported organization")?-If "Yes,"and if you checked 12a or 12b in Part 1,answer(b)and(c)below. 4a b Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign `� z supported organization?If"Yes,"describe in Part W how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations. 4b c Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3)and 509(a)(1)or(2)?If"Yes,"explain in Part W what controls the organization used f a R to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(6) purposes. 4c 5a Did the organization add,substitute,or remove any supported organizations during the.tax year?If"Yes," answer(b)and(c)below(if applicable).Also,provide detail in Part VI,including(i)the names and EIN � numbers of the supported organizations added,substituted,or removed;(ii)the reasons for each such action; (iii)the authority under the organization's organizing document authorizing such action;and(iv)how the action was accomplished(such as by amendment to the organizing document). 5a b Type I or Type II only.Was any added or substituted supported organization part of a class alreadyz ' e` designated in the organization's organizing document? 5b c Substitutions only.Was the substitution the result of an event beyond the organization's control? 5c 6 Did the organization provide support(whether in the form of grants or the provision of services or facilities)to sue` anyone other than(i)its supported organizations,(ii)Individuals that are part of the charitable class benefited s by one or more of its supported organizations,or(III)other supporting organizations that also support or benefit one or more of the filing organization's supported organizations?If"Yes,"provide detail in Part W. 6 7 Did the organization provide a grant,loan,compensation,or other similar payment to a substantial contributor 4M (as defined in section 4958(c)(3)(C)),a family member of a substantial contributor,or a 35%controlled entity M1 with regard to a substantial contributor?If"Yes,"complete Part I of Schedule L(Form 990 or 990-EZ). 7 8 Did the organization make a loan to a disqualified person(as defined in section 4958)not described in line 7? M „3? If"Yes,"complete Part 1 of Schedule L(Form 990 or 990-Q). B. 9a Was the organization controlled directly or indirectly at any time during the tax year by one or more "f 3r disqualified persons as defined in section 4946(other than foundation managers'and organizations described ; t , In section 509(a)(1)or(2))?If"Yes,"provide detail in Part Vl. 9a b Did one or more disqualified persons(as defined in line 9a)hold a controlling interest in any entity in which the supporting organization had an Interest?If"Yes,"provide detail in Part W. 9b c Did a disqualified person(as defined in line 9a)have an ownership interest in,or derive any personal benefit from,assets in which the supporting organization also had an Interest?If"Yes,"provide detail in Part W. 9c 10a Was the organization subject to the excess business holdings rules of section 4943 because of section ` 4943 f (regarding certain Type II supporting organizations,and all Type III non4unctionall integrated tiFk '9 9 YP PP, g 9 YP Y� 9 supporting organizations)?if"Yes,"answer 10b below. 10a b Did the organization have any excess business holdings in the tax year?(Use Schedule C, Form 4720,to determine whether the organization had excess business holdings.) 1013 Schedule A(Form 990 or 990.FZ)2010 Schedule A(Form 990 or 990-EZ)2019 DHWANI ACADEMY OF PERCUSSION MUSIC Pagej 049MM-Supporting Organizations continued Yes N o 11 Has the organization accepted a gift or contribution from any of the following persons? a A person who directly or indirectly controls,either alone or together with persons described in(b)and(c) „,... .....a..: . below,the governing body of a supported organization? 11a b Afamily member of a person described in(a)above? jib c A 35%controlled entitya of a person described in orb above?If"Yes"to a b,or c,provide detail in Part Vt. J11CI Section B.Type i Supporting Organizations 1 Yes No 1 Did the directors,trustees,or membership of one or more supported organizations have the power to E =: regularly appoint or elect at least a majority of the organization's directors or trustees at all times during the tax year?If"No,"describe in Part Vi how the supported organization(s)effectively operated,supervised,or controlled the organization's activities.If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions,if any,applied to such powers during the fax year. 1 i 2 Did the organization operate for the benefit of any supported organization other than the supported n ; 3 organization(s)that operated,supervised,or controlled the supporting organization?If"Yes,"explain in Part W how providing such benefit carried out the purposes of the supported organization(s)that operated, supervised,or controlled the supporting organization. 2 Section C:Type II Supporting Organizations Yes No 1 Were a majority of the organization's directors or trustees during the tax year also a majority of the directors °t i A, or trustees of each of the organization's supported organization(s)?If"No,"describe in Part W how control or management of the supporting organization was vested in the same persons that controlled or managed ,f, the supported organization(s). 1 Section D.All Type iII Supporting Organizations Yes No 1 Did the organization provide to each of its supported organizations,by the last day of the fifth month of the ` organization's tax year,(1)a written notice describing the type and amount of support provided during the prior tax year,(ii)a copy of the Form 990 that was most recently filed as of the date of notification,and(51)copies of the ; r organization's governing documents in effect on the date of notification,to the extent not previously provided? 4 . 2 Were any of the organization's officers,directors,or trustees either(1)appointed or elected by the supported ' w organization(s)or(ii)serving on the governing body of a supported organization?If"No,"explain in Part Vi how the organization maintained a close and continuous working relationship with the supported organization(s). 2 3 By reason.of the relationship described in(2),did the organization's supported organizations-have a significant voice in the organization's investment policies and In directing the use of the organization's � income or assets at all times during the tax year?If"Yes,"describe in Part W the role the organization's e' ' supported organizations played in this regard. 3 Section E.Type III Functionally Integrated Supporting Organizations 1 Check the box next to the method that the organization used to satisfy the Integral Part Test during the year(see instructions). a ❑ The organization satisfied the Activities Test.Complete line 2 below. b The.o anization is the parent of each of its❑ rg p supported organizations. Complete line 3 below. . c . ❑ The organization supported a governmental entity.Describe in Part W how you supported a government entity(see instructions). a 2 Activities Test.Answer(a)and(b)below. Yes No a Did substantially all of the organization's activities during the tax year directly further the exempt purposes of �r\ the supported organization(s)to which the organization was responsive?if"Yes,"then in Part Vi ldentify a i^ those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations,and how the organization determined �`d r_k� ;ems that these activities constituted substantially all of its activities. 2a b Did the activities described In(a)constitute activities that,but for the organization's involvement,one or more of the organization's supported organization(s)would have been engaged in?If"Yes,"explain in Part W the :5 reasons for the organization's position that its supported organization(s)would have engaged in these activities but for the organizations involvement. 2b 3 Parent of Supported Organizations.Answer(a)and(b)below, u M a Did the organization have the power to regularly appoint or elect a majority of the officers,directors,or 5 ,w trustees of each of the supported organizations?Provide details in Part Vl. ga b Did the organization exercise a substantial degree of direction over the policies,programs,and activities of each of Its supported o anizations?If"Yes,"describe in Part Vl the role pLaLed b4 the o anization in this regard. 3b Schedule A(Form 990 or 990-EZ)2019 Schedule A(Form 990 or99o-EZ)2019 DHWANI ACADEMY OF PERCUSSION MUSIC Pa e 6 T e Ili Non-Functionally Integrated 509(a)(3)SupportingOrganizations 1 �] Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov.20, 1970(explain in Part VI).See Instructions.All other T e 111 non-functionally integrated supporting organizations must complete Sections A through E. Section A-Adjusted Net Income (A)Prior Year (B)Current Year (optional) 1 Net short-term capital gain 1 2 Recoveries of prior-year distributions 2 3 Other gross income see instructions 3 4 Add lines 1 through 3. 4 0 0 5 Depreciation and depletion 5 6 Portion of operating expenses paid or incurred for production or collection of gross income or for management,conservation,or maintenance of Rroperty held for production of income(see instructions) 6 7 Other ex enses see Instructions 7 S Adjusted Net Income subtract lines 5 6 and 7 from line 4 . 8 0 0 Section 9-Minimum Asset Amount (A)Prior Year (B)Current Year (optional) 1 Aggregate fair market value of all non-exempt-use assets(see instructions for short tax year or assets held for part of year): a Average monthly value of securities 1a b Average monthly cash balances I c Fair market value of other non-exempt-use assets 1c j d Total add lines 1a, 1b,and 1c I 0 0 e Discount claimed for blockage or others factors(explain in detail in Part VI): . 2 Acquisition Indebtedness applicable to non-exempt-use assets 2 3 Subtract line 2 from line 1d. 3 0 0 4 Cash deemed held for exempt use.Enter 1-112%of line 3,(for greater amount, see instructions). 4 0 0 5 Net value of non-exempt-use assets subtract line 4 from line 3 5 0 0 6 Multiply line 5 b .035, g 0 0 7 Recoveries of prior-year distributions 7 0 0 8 Minimum Asset Amount add line 7 to line 6 g 0 0 Section C-Distributable Amount k vav� v��r a� Current Year 1 Adjusted net income for prior year from Section A,line 8,Column A NIS"" WW 0 2 Enter 85%of Ilne 1 2 Y '� „��? 0 3 Minimum asset amount forprior year from Section B line 8,Column A 3 �� 0 a 4 Enter greater of line 2 or line 3. 4 „<tM s sr 0 5 Income tax imposed in prior year 6 Distributable Amount.Subtract line 5 from line 4,unless subject to emergency tempora reduction see instructions). g 7 [� Check here if the current year is the organization's first as a non-functionally integrated Type III supporting organization(see Instructions). ..._ Schedule A(Form 990 or 990-EZ)2019 schedule A Form 990 or 990-EZ)2019 DHWANl ACADEMY OF PERCUSSION MUSIC Page 7 KOWA Tvne III Non-Functionally Integrated 509 a 3 Supporting Organizations continued Section D.Distributions. Current Year 1 Amounts paid to supported organizations to a0com lish exempt purposes 2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations,in excess of income frorn activity 3 Administrative'ex enses paid to accomplish exempt purposes of supported organizations 4 Amounts paid to acquire exempt-use assets 5 Qualified set-aside amountsjprlor IRS approval required) 6 Other distributions describe In Part VI).See instructions. 7 Total annual distributions.Add lines 1 through 6. 0 6 Distributions to attentive supported organizations to which the organizatlon is responsive (provide details in Part VI).See instructions. 9 Distributable amount for 2019 from Section C line 6 0 10 Line 8 amount divided by line 9.amount 0.000 Section E-Distribution Allocations(sae instructions) (I) Underdistributions Distributable Excess Distributions Pre-2019 Amount for 2019 1 Distributable amount for 2019 from Section C,line 6 a 0 2 Underdistributions,if any,for years prior to 2019 (reasonable cause required—explain in Part VI).See "Instructions. 3 Excess distributions carryover,if any,to 2019 a From 2014. {a w nxa F ,;.a:\ a,92"ra,.°e c.a a a R at.� �� y b From 2015. 0 :�6 kxu, 3 fi,.�; to 1v:NMt Hai s l L. t �Ski� W e From 2016. t) qA1 �H¢. �aa � "�� d From 2017. 0 e From 2018. OF f Total of lines 3a through e t :,t Fa x ea i Applied to underdistributions of prior years h Applied to 2019 distributable amount W' ' ??M 12r', 0 1 Carryover from 2014 not applied see instructions sw ' ` tea Remainder.Subtract Tines 3g,3h and 3i from 3f. 0 4 Distributions for 2019from MW � >r'� R a �aU', Section D,line 7: ` a Applied to underdistributions of prilor years 0 b Applied to 2019 distributable amount ''k`t' � , aa.aF.,; ', 0 j c Remainder.Subtract lines 4a and 4b from 4. 0 �.., �V„ 5 Remaining underdistributions for years prior to 2019,if any.Subtract lines 3g and 4a from line 2.For result greater than zero,explain in Part VI.See instructions. . r 6 Remaining underdistributions for 2019.Subtract lines 3hgr � �� 'F and 4b from line 1.For result greater than zero,explain in 'm M Part V1,See Instructions. � �, �� ` � �e 0 7 Excess distributions carryover to 2020.Add lines 3j , t `a� and 4c. 8 Breakdown of line 7: tau\ \ 7 77 k. A>?v P # tti#%B a Excess from 2015. 0 b Excess from.2016. 0 't, 2.._:2��x�w�a �.�, s< �;.,i.�.' 0 c Excess from 2017. h d Excess from 2018, 0 e Excess from 2019. 0 Schedule A(Form 990 or 990-F_Z)2019 Schedule A(Form 990 or 990-EZ)2019 DHWANI ACADEMY OF PERCUSSION MUSIC' Page Supplemental Information.Provide the explanations required by Part 11,line 10;Part ll,line 17a or 17b;Part III, line 12; Part IV,Section A,lines 1,21 3b,3c,4b,4c,5a,6,9a,.9b,9c, 11 a, 11 b,and 11 c;Part IV,Section B,lines 1 and 2;Part IV, Section C,line 1;Part IV,Section D,lines 2 and 3;Part IV,Section E,lines 1c,2a,2b, 3a,and 3b;Part V,line 1; Part V,Section B,line 1e;Part V,Section D,lines 5,6,and 8;and Part V,Section E, lines 2,5,and 6.Also complete this part for any additional Information.(See instructions.) ------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------=---------------------------------------------------------------------------------------------=----------------------- ---------------------------------------------------------------------------------------------------=-------------------------------------------- ---------------------------------=----------------------------------------------------------------------------------------------------------_--- j . i --------------------------------------------------------------------------------------------------------------------------=--------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------- - i __ --_.---------------------- --- ------_-_----_.--- .._-_..___.---- i - ------------------------------------------------------------:.___---------------------------------------------------------------_.._------------ ------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------.._._---------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------=---- I ------------------_----------------------------------------------------------------.__.-------------__._____---_____------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------ _____..._____-__.._--_-------- ---------------------------------------------------------------.___--_..____-___ --_-_._.----------------------- I ------------------------------------------------------------------------------------------------------------------------------------------------ 1 ------------------.__..____..__---__-__---------------------------------------------------------------------_---------------_-------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------= Schedule A(Form 990 or 990•F2)2019 che {Sperm d le BZ, Schedule of Contributors or 990-13F) ► Attach to Form 990,Form 990-EZ,or Form 990-13F. ®� 9 oepartmenloflheTreasury ► Goto;vwwJrs. Enlsrnal Revenue service gov/Form990 for the latest information. Name of the organization Employer Identification number DHWANI ACADEMY OF PERCUSSION MUSIC Organization type(check one): Filers of: Section: Form 990 or 990-EZ ❑X 501(c)( 3 )(enter number)organization i ❑ 4947(a)(1)nonexempt charitable trust not treated as a private foundation ❑ 527 political organization i Form 990-PF ❑ 501(c)(3)exempt private foundation ❑ 4947(a)(1)nonexempt charitable trust treated as a private foundation ❑ 501(c)(3)taxable private foundation I Check if your organization is covered by the General Rule or a Special Rule. Note:Only a section 501(c)(7),.(8),or(10)organization can check boxes for both the General Rule and a Special Rule.See instructions. General Rule ❑ For an organization filing Form 990,990-EZ,or 990-PF that received,during the year,contributions totaling$5,000 or more(in money or property)from any one contributor.Complete Parts I and It.See instructions for determining a contributor's total contributions. Special Rules ❑ For an organization described in section 501(c)(3)filing Form 990 or 990-EZ that met the 33113%support test of the regulations under sections 509(a)(1)and 170(b)(1)(A)(vi),that checked Schedule A(Form 990 or 990-EZ), Part II,line 13, 16a,or 16b,and that received from any one contributor,during the year,total contributions of the greater of(1) $5,000;or(2)2%of the amount on(€)Form 990,Part Vill,line 1 h;or(Ii)Form 990-EZ,line 1.Complete Parts I and[I. ❑ For an organization described to section 501(c)(7),(8),or(10)filing Form 990 or g90-EZ that received from any one contributor,during the year,total contributions of more than$1,000 exclusively for religious,charitable,scientific, literary,or educational purposes,or for the prevention of cruelty to children oranimals.Complete Parts I, II,and III. ❑ For an organization described in section 501(c)(7),(8),or(10)filing Form 990 or 990-EZ that received from any one dontributor,during the year,contributions exclusively for religious,charitable,etc.,purposes,but no such contributions totaled more than$1,000.If this box is checked,enter here the total contributions that were received during the year for an exclusively religious,charitable,etc.,purpose.Don't complete any of the parts unless the General Rule applies to this organization because It received nortexclusively religious,charitable,etc.,contributions totaling$5,000 or more during the year. . . . . . . . . . . . . . . . . . . . ► $ -------------------------- Caution:An organization that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B(Form 990, 990-EZ,or 990-PF),but it must answer"No"on Part IV,line 2,of its Form 990;or check the box on line H of its Form 990-EZ or on Its Form 990-13F,Part I,line 2,to certify that it doesn't meet the filing requirements of Schedule B(Form 990,990-EZ,or 990-PF). For Paperwork Reduction Act Notice,see the Instructions for Form 990,990-EZ,or 990-13F. Schedule B(Form 990,990•FS,or 990-PF)(2019) HTA Schedule 6(Form 990,990-EZ,or 900-PF)(2019) Page 2 Name of organization Employer identification number DHWANI ACADEMY OF PERCUSSION MUSIC Contributors(see instructions). Use duplicate copies of Part I if additional space is needed. (a) (b) (c) (d) No. Name,address,and ZIP+4 Total contributions Type of contribution ----,---- -------------------------------- --- Person ❑ ---------------------------------------------------------- Payroll ❑ --------._....-------------------------------------------- ❑ - N �------------------------------- oncash Foreign State or Province: -------------______ -- --_---- (Complete Part ilfor Foreign Country:________- A -_-_-_ _ noncash contributions.) (a) (b) (c) (d) No. Name,address,and ZIP+4 Total contributions Type of contrlbution --------- ----------------------------------------- -- Person ❑ -------------------- ------------------------------------ Payroll ❑ -- ------------------------------------------------------ Noncash ---- --- _ ❑ Foreign State or Province: ------------=- - ______________ (Complete Part II for Foreign Country:____ - noncash contributions.) (a) (b) (c) (d) No. Name,address,and ZIP+4 Total contributions Type of contribution ______ Person ❑ --------------------------------------------------------- Payroll ❑ ------ --- ---- -- - --- - --- -- -- ----- - --- - --------------- - ------- Noncash -- El___ _ Foreign State or Province: _ ___________ ___ _'_ ___- (Complete Part II for Foreign Country: ________________ noncash contributions.) (a) (b) (c) (d) No. Name,address,and ZIP+4 Total contributions Type of contribution --------- ___________________________ ----- Person ❑ ---------------------------------------------------------- Payroll ❑ ------------------------------- Noncash Foreign State or Province: _____ (Complete Part llfor Foreign Country: noncash contributions. (a) (b) (c) (d) i No. Name,address,and ZIP+4 Total contributions Type of contribution -------- --------------------•-- Person ❑ --------------------------------------------------------- Payroll ❑ -- -------------------------- - Noncash ❑ Foreign State or Province: _______ (Complete Part II for Foreign Country:........................................ noncash contributions.) (a) (b) (c} (d) . No. Name,address,and ZIP+4 Total contributions Type of contribution --------- ------------------------------- -- Person ❑ --------------------------------------------------------- Payroll ❑ - �------------------------------_ Noncash Foreign State or Province: ............................... (Complete Part II for Foreign Country:-------- -----_________-_- noncash contributions.) Schedule B(Form 990,990-EZ,or 990.PF)(2019) Schedule B(Form 990,990-EZ,or 990-PF)(2019) Page 3 Name of organization Employer identification number DHWANI ACADEMY OF PERCUSSION MUSIC Noncash Property(see instructions). Use duplicate copies of Part ll if additional space is needed. (a)No. {c) from Description of noncash property given FMV(or estimate) Date received Part I (See Instructions.) ------------------------------------------------------------- ------------------------------------------------------------. ------------------ - -------------=--------------------------• $----------------------------- ---------------------------- (a)No. from (b) FMV(or estimate) (d) Description of noncash property given Date received Part I (See instructions.) ------------------------------------------------------------- -------- ------------------------------------------------------------- ------------------------------------------------------------- ------------------------------------------------------------ $ ---------------------------- ----------_..__------------- i (a)No. . b (c) from ( ) FMV(or estimate) (d) Description of noncash property given Date received Part I (See Instructions.) ------------------------------------------------------------- ------------------------------------------------------------- ------------------------------------------------------------- - ---- ---- - - - --- - - --- --- -- -- - - $----------------------------- ---------------_------------- (a)No. (c) from (b) FMV(or estimate) Part I (See Instructions.) (d) Description of noncash property given Date received --------------------------- __.----_-------------------------- � -------- ------------------------------------------ ---------------- ------------------------------------------------------------- (a)No. (c) from Description of noncash roe FMV(or estimate) (d) Part I p property rty given (See instructions.) Date received --------- --------------------------------------------------------------- -------------------------------------------------------------- --------------------------------------------------------------- $---------------_---_.-. ----- ---------------------------- (a)No. (c) ) from (b) FMV(or estimate) (d Description of noncash property given Date received Part I (See instructions.) -------------------------------------------------------------- --------- --------------------------------------------------------------- ------------------------------------------------------------- ------------------------------------------------------------- $----------------------------- ---------------------------- Schedule 0(Form 990,990-EZ,or 990-PF)(2019) Schedule B(Form 990,990-EZ,or 990-PF)(2019) Page 4 Name of organization Employer Identification number DHWANI ACADEMY OF PERCUSSION MUSIC Exclusively religious,charitable,etc.,contributions to organizations described in section 501(c)(7),(8),or (10)that total more than$1,000 for the year from any one contributor.Complete columns(a)through(e)and the following line entry.For organizations completing Part III,enter the total of exclusively religious,charitable,etc., contributions of$1,000 or less for the year.(Enter this information once.See Instructions.) ' ► $ 0 -------------------------- Use duplicate copies of Part III if additional space is needed. (a)No. from (b)Purpose of gift (c)Use of gift (d)Description of how gift Is held Part I ----------------------------------------- ---------------------- ------------------------------------ ---------------------------------- ------ I ------- -------------------------------- ------------------------------------ ----------------------------------- --- (e)Transfer of gift i t Transferee's name,address,and ZIP+4 Relationship of transferor to transferee j -------------------------------------------------------- ---- --- -------------------------------------------------------- -------------------------------------------------------- -- --- -------------------------------------------------------- -------------------------------------------------------- -- --- ------------------------------------ ------------------ For.Prov. Country (a)No. from (b)Purpose of gift (c)Use of gift (d)Description of how gift is held Part i ------------------------------------ ---------------------------------------- -------=--------------------------------- ----------------------------------- ---------=------------------------------ (e)Transfer of gift Transferee's name,address,and ZIP+4 Relationship of transferor to transferee -------------------------------------------------------- ------ ---------------------------------------------------------- -------------------------------------------------------- - - ---- ------------------------------------------------------- -------------------------------------------------------- - ------------------------------------------------------ For.Prov. Country (a)No. from (b)Purpose of gift (c)Use of gift (d)Description of how gift is held Part ---------------------------------------- ------------------------------------ -------------------------------------__- -------- ---------------------------------------- ------------------------------------ --------------------------------------- (e)Transfer of gift Transferee's name,address,and ZIP+4 Relationship of transferor to transferee i -------------------,.._-_--___ --------- ------------------------------------------------------------------- -------------------------------------------------------- ------------------------------------------------------------------ -------------------------------------------------------- -___.__._----- --------------------------------------- ----------- For.Prov. Country (a)No. from (b)Purpose of gift . (c)Use of gift (d)Description of how gift is held I Part ._.--_.___-.._.._--------------_--_--__-- ------------------------------------ ---------------------------------__----__ -----_----_-__.._._..--- -----------.._.._-_. ------------------------------------ --------------------------------__-_----_ (a)Transfer of gift e Transferee's name,address,and ZIP+4 Relationship of transferor to transferee ___ ___ ________ _________________ ___________________ ----------------------------------------------------__-_-___..___ For.Prov, Gount Schedule B(Form 990,990-EZ,or 990-PF)(2019) SCHEDULE O Supplemental Information.to Form 990 or 990-EZ OMB No.154MO47 (Form 990 or 990-EZ) Complete to provide Information for responses to specific questions on �O Form 990 or 990-EZ or to provide any additional Information. Attach to Form 990 or 990-EZ. 19 internal •,• , Department Go to wwwJrs. ov/Form990 for the latest Information. ,• , al Revenue Service of the Treasury •v e � Name of tho organization Employer identification number DHWANI ACADEMY OF PERCUSSION MUSK Farm 990-EZ,Part 1,Line 16,Other Expenses_Travel_8,383 ___- - -- ---- -- -- - ------ ----- - ------------------------------ ------------------------------- Farm 990_EZ,Part I,Line 16,Other Expenses;Meals and entertainment:252 Form 990_EZ,Part I,Line 16,Other Expenses:Conferences.conventions,and meetings_225 ---------------------------------- Form 990_EZ,Part I,Line 16,Other Expenses:5upplies_23__ Farm 990_EZ,Part 1,Line 16,Other Expenses:Telephone:648 1----------------------------------------------------------------------------- Farm 990 EZ Part I Line 16 Other Expenses Parking:600 r - ---- --- -- --- ---- ---- --- --- - - ------------------------------------------------------------- Form 990-1=Z,Part I,Line 16,Other Expenses_Office Expense:5,040 - - - - - --- -- - --- ------- ------------------------------------------------------------------ Form 990-1=Z,Part I�Line 16,Other Expenses_License Permits&Fees_ 1,388 - ----------------------------------------------------------- Farm 990-EZ,Part 1,Line 16,Other Expenses:Lease Expense_4,500 -- - --- -,- - - - ---- ---- - ----------_----------------------------------------------------- _----- 9_qm 990_EZ,Part I, Line 16,Other Expenses: Internet Expense:934 - - ------------------------------------- ----- Form 990-EZ,_Part I,-Line-1 6;Other Expenses Insurance_5,430 Form'990_EZ,Part I,Line 16,Other Expenses:Dues&Subscription_554 Farm 990_EZ,Part 1,Line 16,Other Expenses_Auto Expense_5,182 - - - - - --_---- - --------------------------------------------------------------------- Farm 990-EZ,Part I,-Line-1 6,Other Expenses_Bank Charges:502--- Form 990-1=Z,Part 1,Line 16,Other Expenses_Accounting Fees:2,100 Farm 990_EZ,Part I,Line 16.Other Expenses_Program Expenses_41 ------------------------------------------------------------. Farm 990_EZ,Part 1,Line 16,Other Expenses:Utilities_717 Farm 990-EZ,Part I,Line 16,Other Expenses:Security_ 0 ------------------------------------..___- 15 ---------_-_-----------------------------------------------------__.._. Form 990-EZ,Part II,Line 24,Other Assets:OTHER A551=i 5:Be�innin�of year:^1,000,End of ------------------ - ---- - ------...___sets---THE -----ETS.- - - ----------------------------------------- dear_10D - - Form 990_EZ,Part 11,Line 26,Liabilities:PAYROLL LIABILITIES;Beginning ofyear 4,363, End a of year 5,680 ---------------------------------------------._-.._.__-------------------------------._...__------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- For Paperwork Reduction Act Notice,see the Instructions for Form 990 or 990-EZ. Schedule a(Form 990 or 990-EZ)(2019) HTA Schedule 0(Form 990 or 990-EZ)(2019) Page 2 Name of the organization Employer Identiflcation number DNWANI ACADEMY OP PERCUSSION MUSIC --------------------------------------------------------------------------------------------------------------------------------------------- --------------=------------------------=---------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------- -------------- =------------------------------------- - E -------------------------------------------------------------------------------------------------------------------------------------------- i ---------------------------------------------------------------------------------------------------- -------------------------------------- ------------------------------------------------------------ ------------------------------------------------------------------------ =------ ---------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------. ______---_----------------------------- --=--------------------------=---------------------------------------------------------------------------------------- 1 -----------------------------------_------------------------------------------------------------------------------------ ------------------------------------------------------------- -------------------------------------=---------------------------------------- -------------------------.___---------------------------------------=---------------------------_--- -------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------_-_-------------------------------------------------------------- _------- ---------------------------------------------------------------------------------------------=------------------------------------------------ -------------------------_-------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- Schedule 0(Form 990 or 990-EZ)(2019) Dhwani Academy of Percussion Music (NEW) Eligibility Checklist (staff use only) Eligibility YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/project/event Identify how the funds will be used to benefit the Cupertino X cammunity Be awarded only once per project X For specific needs,not on going,operational costs X Have more than 75%of the requested funds allocated for direct X 26%or more of the requested funds were allocated toward expenses not directly service costs versus administrative costs tied to the proposed program/event/project(i.e.:organizational staffing costs) Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only NA submit one application Proceeds generated from the funded activity may only be used for Based on the information provded in the application,allocation of proceeds the conducted activity generated could not be determend. admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved Fees will be charged for the requested program/event/project.Approval required by Parks and Recreation Commission from Parks and Recreation Commission. City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Community Funding Grant in the past? 0 Yes No If, Yes,when? Legal Name of Organization: Kalashree Foundation Inc. Web Address: Mailing Address: City: Redwood City Zip: 94065 Phone: President/Executive Director:Khan Kulkarni Title: Email: Telephone Number: kiran@kalashree.us Contact Person: Kiran Kulkarni Title: Vdlrinteer Email Address; kiran@kalashree.us Telephone Numbec 591(c)(3)? Q Yes 0 No Year Established 2013 Federal Tax ID Fiscal Sponsor Name: Fiscal Sponsor Address: City: Zip: Phone: Total Organization Budget: $30,000 Total#of Board Members: 4 Total #of staff: 0 Total#of Volunteers: 15 Mission Statement: The Kalashree Foundation is a charitable nonprofit 501(c)�3)organization founded by Vidushi Kala Ramnath with the purpose of making the world a better place through classical Indian music. The emphasis on musical education for underprivileged children is emphasized- Cross-cultural musical events build bridges, as Kalashree seeks to connect with musicians from other traditions and cultures in an active dialogue. This is the best way to model peace through diplomacy, and Kalashree's mission embodies this in daily practice. Kalashree uses the advantages of digital platforms and modern technologies to connect students to musical training regardless of their location. Preserving the roots and cultural practices of classical Indian music thro�Agh active participation is critical. The growing need for community in conditions of social isolation makes this mission increasingly relevant in the world today.Musical training and promotion of young musicians ensures the survival of this art. Brief Description of Organization: The Kalashree Foundation was launched to expand the reach of Indian classical music. The Foundation's core musical education program enacts the organization's mission through active engagement with communities. This also helps to solidify the cultural presence of classical Indian music, locally within Cupertino City's communities and globally, via the digital platform. The outreach plan provides direct benefits to the local and world-wide communities by connecting learners with distinguished artists in the field of Indian classical music. Three years of successful programming of workshops and concerts represents a major programming milestone. These events featured aspiring young artists musically trained through Kalashree. This helped to pave the way for more ambitious agendas, like the Virtual Library Project. This library forms the apex of our overarching goal to preserve Indian musical culture for future generations. These events are produced by dedicated volunteers. Brief Description of Services Provided: The Kalashree Foundation's annual musical education program is at the heart of our services provided to the community, This program initiates the community into Indian music through concerts. Follow-up workshops and an annual student concert cempiete the program. It was designed to embed classical Indian music within Cupertino City and the greater global Indian music communities. Participants benefit from an enriched inner life through close interaction with distinguished Indian classical musicians. Kalashree leverages the advantages of digital platforms and modern technologies to connect students to musical training regardless of their iocation in the world. In-person concerts and workshops expose Cupertino residents to this ancient art form. Preserving the roots and cultural practices of classical Indian music through active participation is an essential service we provide, The growing need for human connection makes this mission incredibly relevant in the world today. SECTION 4: GRANT REQUESTS 1.Program/ProjectlEvent Name: Indian Classical Music: Concert 8 Workshop Program 2. Date(e)and/or duration of program/projecUevent(ff applicable):Annual program for 2022 3. Total program/projectlevent budget: $9.999 4. Requested Amount: $9,999 Percent of total program/projecUevent budget; 100% 5. PrograrNProjecl projected income: $0 Percentage of your organization's projected income: 0% 6.Type of Request: O Capital Improvement 0 Program Support D Event O One-time project ❑Other: 7.This grant will fund a(n): 0 Existing program/projecUevent;established in 2014(year) D New program/projecUevent 8. Describe the purpose of requested funds and the services that will be provided: Kalashree Foundation meticulously laid the groundwork for the annual program over three years of previous production.This summary of services provided accurately represents a similar program schedule for the next year- -the purpose of our funding request. Annual program outline: • May-A classical Hindustani vocal concert featuring Pritam Bhattachadee, a disciple of the legendary Pandit Jasraj. • October-A public presentation of an online concert. connecting cultural artists with the greater community of Indian music supporters using livestreaming technology for the first time. •Vocal workshops organized and produced by Kalashree in August. • Guru Poornima is an annual event where students perform what they've learned in a traditional concert format. This annual program happens in four stages over a one-year period. Each stage carefully reinforces the others, This program is separate from other costs of operating Kalashree. Funds expand the program's reach, 9. Please provide a line item breakdown of how the funds will be used in the categories below. If a category is not a livable, put$0: Admin Staff $ b Materials/E ui ment $200 Entertainment $100 Room/Venue Rental $2,000 Other Professional Services Artist Fees $4,500 Other Marketingand Advertising $200 oral $7,000 10. Explain how the request aligns to City mission and values: Kalashme Foundation meticulously laid down the groundwork for a complete musical education program for Cupertino and the general public. The programming in previous years already aligns with the city's values.This is evidenced by the close collaboration between volunteers, students and community members. Responsibility is essential for every successful event.Each stage of the project was designed to be carefully inter-connected and mutually reinforcing. Students and volunteers collaborate to make each concert and workshop a meaningful event that Is culturally enriching.This example demonstrates how community members take responsibility for their musical development as participants or audience members who encourage others to attend. Finally,the virtual library project will eventually enable new listeners to stay connected and learn more about this musical tradition online from any location.This innovative initiative opens up learning opportunities,globally. 11. Describe how the program/projecUevent fills a community need.Who identified this need?What other similar projectlprogramlevent exists to serve Cupertino residents?How is your proposed projecUprogram/event unique from similar projects/programs/events or how do you collaborate to avoid duplication? Kalashree'a community education program is based on the ancient arts of India,which are novel to many residents of Cupertino. Therefore, Kalashree Foundation is also uniquely qualified to address these needs through regular exposure to the depth of Indian classical music traditions, methods and pedagogies. Classical Indian music enriches the lives of those touched by its mystical ambience, intellectual rigor and intuitive qualities. Many Cupertino residents were introduced to Indian classical music through a concert. Feedback from attendees of previous events Informed our awareness of the need for more events. Undoubtedly, the musical experience can be profoundly moving.Audiences are often touched by the unique attributes of Indian music during their fret concert. Follow-up workshops meet the needs of those seeking a deeper understanding. Serious students gain access to the Guru Poornima program event,which uplifts their musical achievements in a supportive public setting. 12. Who will be served by this grant? Cupertino City residents are the primary and target beneficiaries of the activities funded by this grant.A sample of previous years'events demonstrates our capacity to serve residents using the Cupertino Citys available facilities: • May 2019 -Concert: City Cupertino Hall • October 2018—Workshop: Cupertino Residence • July 2017—Workshop: Cupertino club house The number of attendees at these events ranged from 15 to 150, and most of them were Cupertino residents. a)Number of Individuals total: 150 b)Number of Cupertino residents: 100 c)Particular community groups: Music is a universal language,yet Indian music offers an intriguing dialectic.Classical Indian music attracts people from all walks of life,demographics and backgrounds.Although our program seeks to reach as many new Cupertino residents as possible,we have an established base of avid Indian music lovers who form the core of our network.Our Virtual Library continues the effort to expand our reach to new listeners,students and supporters online.This content also serves the general public. d)Will the program/projectlevent be available to the entire community/public or are there any eligibility criteria? The program is divided into three events and online content. Naturally,the online content is freely available to the entire world. Concerns are open events with no eligibility criteria;we welcome all who listen. Workshops are open to musicians who wish to learn more about this music. Importantly,this is not an eligibility restriction; anyone with an Interest in a workshop is welcome b participate.The Guru Poornima event is a showcase of student talent,but anyone can attend. e)WIII there be a charge or fee for the program/projectlevent(ff applicable) Admission to all annual program events supported by the city grant will be publicized on all of our outreach literature as"free of charge."Support from the Cupertino Community Funding Grant will have a measurable impact on the content:free musical exposure and education is more beneficial for participants and the community; it keeps the focus where it needs to be: on the music.The City's contribution—in this particular regard--will be acknowledged in formal promotional materials. f)What outreach methods does your organization use to promote the program/project/event(d applicable)? Publicizing to our network and the general public expands our reach. Local volunteers spread the word about our events with neighbors, Mends and family.We have the support of local shops for Flyer distribution. This includes local Indian grocery stores, which help us reach members of the Indian musical community. Community boards at these locations have a measurable effect on turnout. Continuity of programming is central to this effort when the community sees our Flyers year after year. 13. Describe how the funds will be used to benefit or Impact the Cupertino community: Benefits to Cupertino's community members are well-established, based on feedback from previous participants. This grant will help us to develop each stage of this program to better serve the community and increase their awareness of the breadth and depth of this traditional art. The overarching strategy is to expose the public to Indian classic music in four stages: 1.Stage one is usually the first exposure to this music through a professional concert organized by Kalashree Foundation.This provides an opening for additional engagement by anyone who inquires. 2.Workshops open the door to participation of interested attendees from the concert. 3. Student renditions are showcased at the culmination of this project—the Guru Poomima event, a concert simulation for student musicians.. 4.Our Virtual Library Project is in development. It will be an online resource that keeps the community connected and engaged in music during intervals between events. 14. Demonstrate that the member implementing and managing the program/project/event have adequate experience: Kalashee Foundation has the qualified and experience staff capable of producing events in a welcoming, open-to- all environment.Opportunities for students to perform publicly were organized by Kalashree's incredibly dedicated project manager, Kimn Kulami. He coordinated the volunteers, city location and logistics. Kiran leads Kalashree's efforts to produce concerts, manage artists, technology and studio recordings. Khan fully recognizes the effort required to cultivate the understanding of Hindustani music in Cupertino. This only fuels his commitment to organizing workshops and lecture demonstrations by renowned artists and musicologists. Kiran's areas of expertise include: Event Management,Technology Management,Artist Management, Studio AN Recordings,Professional Concerts and Organization Management. Kiran's C.V. is best represented by the various projects he has produced through Kalashree,and details are available at https://kalashree.uslprojects. 15. How will success of the program/project/event be measured?: Program longevity is the Ideal metric of success. However,short-term mantas can be evaluated in terms of quality as well as quantity.On the qualitative side, the musical depth of understanding of students at the annual Guru Poornima event is a serious and reliable metric. It tracks student improvement and development over time. For example,some ragas are relatively easy to play for beginner students.As the student's musicianship matures,the ragas selected for such a student may increase in difficulty.This is qualitative metric that is observable externally to any informed third parry. Quantitatively, we track community impact by the number of people who attend events.We expect to see an increase in this number over time; however, several uncontrollable variables, including organizational branding and exposure rates,affect it.These variables change over time. Imprecision doesn't diminish the value of utilizing a quantitative metric:it keeps it in perspective. 16. Will more than 75%of the requested funds go towards direct service costs versus administrative costs? O Yes O No 17, Will you collaborate with other organizations to deliver the program/projecVevent funded by this grant?If so, which organizations? Other organizations have been involved in previous collaborations in our annual program.Although we can certainly expect this participation to continue, it Is contingent on our resources. If the program is scaled down to a minimal degree,we are less likely to enroll the services of table accompanists from the Dhawani Academy of Percussion,as we have done in the past,for example.The Rithwik Foundation is a partner organization for expanding the reach of our events to a global audience. Funding this program makes video livestreaming and/or documentation much more likely to occur.Although the benefits to Cupertino are indirect in this case, it's also important to note that these global outreach efforts tend to attract positive attention to Cupertino City on an international scale.The benefits of such positive public relationships cannot be quantified. Finally,the same Cupertino City volunteers who helped us in the past are also engaged in making this annual program a success. 18. If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants, please describe this support: The Kalashree Foundation benefited from city volunteers who assisted the organization in the early days in obtaining 501(c)3 status. Although this support is critical to our ability to function in the city, it might not qualify as in-kind support under the definitions of this grant Because this is an ambiguous area, it is being described here for clarity.Kalashree Foundation also benefitted from discounted venue rentals for the program hosted at city facilities like Quinlan center and Community Hall.We receive no financial support from the City of Cupertino. 19. Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of program/projecVevent(e.g.fee waivers)? If so,please describe this anticipated support: The Kalashree Foundation doesn't receive any kind of fee waivers, but nonprofit discount rates do apply to our organization's activities. We are unaware of the definitions used to determine if the nonprofit discount qualifies as tn-kind support; however, to this date,it can be said that no financial support from the City of Cupertino has been received by Kalashree Foundation. 20. If you are a mufti-jurisdictional organization,describe any funding requested from other agencies/organizations in regards to this program1project/event request. Indicate whether the funding was granted, denied, or is still pending: None expected: Kalashree is a 501(c)3 non profit organization based out of California 21. How would you fund the program/project/event if you do not receive the requested funding?: Donations and contributions are always pursued, under all conditions. However, they vary in direct relation to contingencies. For example,the pandemic curtailed our level of donations.Sudden interruption in programming, especially concede,created a widespread sense of insecurity and instability. The psychological Impact inevitably impedes the willingness of supporters to donate at previous levels. Therefore, maintaining stable programming in spite of all setbacks forms the new foundation of our organization efforts to eventually obtain a secure stream of funding,regardless of external circumstances. In the absence of a city grant,we would scale down the event. This will reduce its community impact. The space used itself will have a smaller capacity,as social distancing will still apply. The limited program would become a small,ticketed event.To wit: Grant funding amplifies our ability to reach more Cupertino residents; but, ultimately— the show must go on. i 1. If you received a Community Funding Grant in prior years, indicate the amounts for each year and describe how those funds were used: 2. If you received a Community Funding Grant last year: a. Please provide a line item breakdown of how the Community Funding Grant was used last year in the categories below. If a category is not applicable, put$0: i, Admin Staff ii. Materials/Equipment iii. Entertainment iv. RoomNenue Rental v. Other Professional Services i. Other Total $0 b. Who was served by the grant last year? i. Number of individuals total: ii. Number of Cupertino residents: iii. Particular community groups iv. Was the program/project/event available to the entire community/public or are there any eligibility criteria? v. Was there a charge or fee for the program/project/event (if applicable)? vi. What outreach methods did your organization use to promote the program/project/event (if applicable)? c. Was the program/project/event successful? Please indicate how success was measured: 3. Please indicate any additional funding received last year from other sources and provide your financial statement if available: Attachments: Attach your financial statment, and any other helpful information about your project. Financial Statements.docx Program Manager Signature Volunteer Date Signed 02/01/2021 Financial Statements: Small Nonprofit Budget Prior Previous Fiscal Year Recently Completed Fiscal Fiscal Year Year f i Insert dates below as Insert dates below as MM/DD/YY- MM/DD/YY MM/DD/YY- MM/DD/YY Dates 01/01/2018— 12/31/2018 01/01/2019—12/3112019 01/01/2020— 12/31/2020 Contributed $26400 $21,000 $30000 In-Kind Contributions W TOTAL REVENUE $26400 $21,000 Y $30000 Previous Most Recently Current Fiscal Year, Fiscal Year Completed Fiscal Year, PROJECTED ACTUAL i Dates 01/01/2018— 12/31/2018 01/01/2019— 01/01/2020—1213112020 i 12/3112019 I Program and Service $7500 $8000 $12500 Expenses General& $500� Administrative $1000 $1000 TOTAL EXPENSES $8000 $9,000 $13,500 Kalashree Foundation (NEW) Eligibility Checklist (staff use only) Eligibility YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/project/event W. Identify how the funds will be used to benefit the Cupertino X community Be awarded only once per project X For specific needs,not on.going,operational costs X Have more than 75%of the requested funds allocated for direct service costs versus administrative costs X Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only submit one application NA Proceeds generated from the funded activity may only be used for NA the conducted activity admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved NA by Parks and Recreation Commission City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Community Funding Grant in the past? 0 Yes No If, Yes, when? .i'11ATIC Legal Name of Organization: Monta Vista High School Speech Boosters Inc Web Address: https:/Imvsd.teaml Mailing Address: 21840 McClellan Road City: Cupertino Zip, 95014 Phone: President/Executive Director: Meera Srinivasan Nalesan Title: Email: rnvsboosters@bgrnail.com Telephone Number: Contact Person: Ra' w ri M h in m Title: ecre Email Address: Telephone Number: 501(c)(3)? * Yes No Year Established 2017 Federal Tax ID. Fiscal Sponsor Name: Monta Vista High School Speech Boosters Inc Fiscal Sponsor Address-. 21840 McClellan Road City: Cupertino Zip.95014 Phone: SFCTlON 3 ORGAN17ATION INFORMAL . Total Organization Budget: $93,349 Total#of Board Members: 3 Total ft of staff: 8 Total#of Volunteers: 4 Mission Statement: We are a 501(o)(3) non-profit organization with the rnission to support and strengthen the Speech program and community at Morita Vista High School, Cupertino CA 95014. Our program priorities are: Support our students in their goal to continuously improve their public speaking and argumentation skills Increase team participation and success Provide coaches and resources to inspire learning Expand the reach of the Morita Vista Speech program Brief Description of Organization: To provide instruction, facilities, opportunities, equipment and resources for participants to engage in the promotion and participation of the activity of Individual Speaking Events (Speech) To sponsor, host and/or participate in events and activities that promote the activity of Individual Public Speaking Events (Speech) To support students in their journey to gain poise and confidence through competitive success To channel resources to help the Monta Vista High School Speech team achieve top rankings at the regional and national level To build community among speech members, parents, alumni, and coaches to facilitate a strong team culture Brief Description of Services Provided: To create a long-lean sustainable fund [or the Morita Vista Speech program in order to sponsor the projects and initiatives that benefit the cause of excellence in public speaking To provide additional resources For the Monta Vista Speech program through educational curriculum and/or the hiring of experienced personnel To sponsor expenditures to tourriamen€s at a significant distance from MVHS To support Speech members in their journey to build ex❑eIlence and rigor in public speaking through coaching students at the high school, middle school and elementary school levels To sponsor the Annual Speak Up! Summer Program, a speech program for incoming FUHSD freshmen To build the Monta Vista Alumni Network .; GRANT REQUESTS 1. Program/Project/Event Name: Monte Vista Speech Program 2. Datil andlor duration of program/project/event(if applicable):Fiscal year 2021 .22(July 2021 -June 2022) 3.Total program/projecf/event budget: $93,349 4. Requested Amount: $13,024 Percent of total program/projecVevent budget: 14% 5. Program/Project projected income: $61,320 Percentage of your organization's projected income:66% 6.Type of Request: U Capital Improvement 0 Program Support D Event D One-time project O Other. 7.This grant will fund an: 12 Existing program/project/event; established in 2017(year) Cl New program/projecVevent B. Describe the purpose of requested funds and the services that will be provided: [11 Strive to provide excellent public speaking education and competition opportunities for our growing student body despite declining member donations during the COVID pandemic [a] Hire and support additional coaches/instructors [b] Hire additional tournament supervisors [c] Invest in speech instructional materials Note: Membership is expected to hit 150 students in 2021.22. [2] Broaden the summer camp to increase the level of professional coaching and encompass several branches of public speaking. Open to all incoming FUHSD freshmen. [3] Initiate Speech scholarships to provide financial aid to deserving MVHS students for participating in summer camp and tournaments, and for recognizing excellence and outstanding contributions to public speaking. 9. Please provide a line Item breakdown of how the funds will be used in the categories below. If a category is not applicable, put$0: Admin Staff $10.02 Materials/E ul ment $ Entertainment $ Room/Venue Rental $ Other Professional Services $ Other Scholarships $3,00 Dial $13.02 10, Explain how the request aligns to City mission and values: MV Speech Boosters extends the mission of our city by providing support and opportunities for our student community to take responsibility and leadership roles as well as sharpen their public speaking and communication/collaboration skills. Our successful feeder middle school program provides leadership and mentor-ship roles for our speech members. Our success in tournaments proves the effectiveness of our coaches. Monte Vista Speech team is ranked 4th In California and 118th nationwide. 11. Describe how the progrenJproject/event fills a community need.Who identified this need?What other similar projectlprogra ilevent exists to serve Cupertino residents? How is your proposed project/program/event unique from similar projects/prugramslevents or how do you collaborate to avoid duplication? With social media and taxting replacing other activities, our youngsters spend less time with their friends in person —perhaps why they are experiencing unprecedented levels of anxiety, depression, and loneliness. Our program helps our students develop the courage to speak up, make friends and have the time of their life. Monte Vista Speech is Into Its fourth year of its five year strategic plan: Speak Up.Be Heard, Cupertino High School has a similar non-profit organization called Cupertino High School Speech&Debate Boosters. We have several programs that are unique such as leadership roles to support our feeder Kennedy middle school speech club,summer camp, etc. Monte Vista Speech team is ranked 4th in California and 1 Bth nationwide. Results of a Satisfaction Survey:100%of the students and parents surveyed said they would recommend the Summer Camp to new members, and reported an average satisfaction score of 9.15110(Students: 8,76, Parents: 9,55). 12. Who will be served by this grant? All middle (Kennedy, Lawson)and high school (Morrie Vista)students I children in the community served by the Monte Vista area of the city of Cupertino. Monte Vista high school currently serves approximately 2,350 students in grades 9-12. Kennedy middle school currently serves approximately 1,198 students in grades 6.8. Lawson middle school currently serves approximately 1,138 students in grades 6.8. a)Number of individuals total: 4,686 b)Number of Cupertino residents: 50,000 c) Particular community groups: All middle (Kennedy, Lawson) and high school(Monte Vista)students/children in the Community served by the Monte Vista area of the city of Cupertino. Monte Vista high school currently serves approximately 2,350 students in grades 9-12.Kennedy middle school currently serves approximately 1,198 students In grades 6-8. Lawson middle school currently serves approximately 1,138 students in grades M. d)Will the program/project/event be available to the entire community/public or are there any eligibility criteria? All middle(Kennedy, Lawson)and high school (Monte Vista)students/children In the community served by the Monts Vista area of the city of Cupertino. Monte Vista high school currently serves approximately 2,350 students in grades 9.12.Kennedy middle school currently serves approximately 1,198 students in grades 6-8. Lawson middle school currently serves approximately 1,138 students in grades 6-8. e)Will there be a charge or fee for the program/projecVevenl(If applicable) There is no charge or fee for this program.We entirely rely on contributions from the parent community to provide all our members a comprehensive speech curriculum, high-quality Instruction and tournament preparation.We encourage a voluntary donation from our members at the time of registration, 0 What outreach methods does your organization use to promote the program/projecVevent(if applicable)? Monte Vista Speech student-run outreach methods such as the MVSD website,quarterly newsletters and social media platforms, Irstagram, and team bonding events to build a strong team culture and Community. We also host several events such as Parent Info Night, Parent Judging Night and Parent Coffees, etc. to build and strengthen the Community among MVHS Speech, Parents, Coaches,and program supervisors. Kennedy middle school speech club Communication and PeachJar mailing list. 13. Describe how the funds will be used to benefit or impact the Cupertino Community: To provide instruction,facilities,opportunities, equipment and resources for participants to engage in the promotion and participation of the activity of Individual Speaking Events (Speech). To sponsor, host and/or participate in events and activities that promote the activity of Individual Speaking Events (Speech). To support students in their journey to gain poise and confidence through Competitive success. To channel resources to help the Monts Vista High School Speech team achieve top rankings at the regional and national level. To build Community among speech members, parents,alumni, and Coaches to facilitate a strong team culture. 14. Demonstrate that the member implementing and managing the programlprojecUevent have adequate experience: Head coach: Gavin Wong is in his fifth year as the Head Speech Coach at Monte Vista High School. Before Monts Vista, Gavin was the Speech Coach at Biala University.As a student at Monte Vials, he founded the Kennedy Speech Team. Gavin heads NAMER Gas and Strategy at a tech firm in San Francisco. He has a Bachelor's Degree in Business Administration from Biala University. He is a recipient of the NSDA Donus O. Roberts Quad Ruby Coach Award(2017). Assistant Coaches: Resume of the assistant coaches here:hftps:/Imvsd.leanVcoaches/ Terri Ettinger-Speech judge for FBLA, CLASH and ToastMasters compefitions. Eric Gras-finalist at the James Logan Invitational in Extemporaneous Speaking (2014), Original Oratory (2014) and in Original Advocacy(2015). Yeshar Hadi-qualified and finaled at the State tournament (2009)and qualified to the National tournament(2011). Amite Mahajan-She was ranked by the NSDA as Top 10 in California for Original Oratory. 15. How will success of the program/project/event be measured?: 11] Hire additional coaches and chaperones for the year-round speech program to support the increased members/ Speech Categories. (21 Strive for membership to hit-150 students. [3] Summer Camp expands to encompass additional public speaking categores; -50 studeri professional coaches and 20+student volunteers. [4]Scholarships granted to support deserving students for summer camp and tournament participation,and recognize excellence and outstanding contributions to MV Speech, 15] Facilitate hybrid onlinelin-person season. 16. Will mare than 75% of the requested funds go towards direct service costs versus administrative costs? ® Yes O No 17. Will you collaborate with other organizations to deliver the prograelproject/event funded by this grant? If so, which organizations? No, TBD 18. If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants, please describe this support: Not Applicable as this is the first lime we are applying for grants. 19. Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of program/projectlevent(e.g.fee waivers)? If so, please describe this anticipated support: No (not aware of any other grants outside of the Community Funding Grants). 20. If you are a multi-judsi icfional organization, describe any funding requested from other agencieslorganizations in regards to this program/project/event request. Indicate whether the funding was granted,denied,or is still pending: Not Applicable as this is the first time we are applying for grants. 21. How would you fund the progmm/projectlevent if you do not receive the requested funding?: Continue requesting a one-time voluntary donation from our members. We may not be able to hire additional coaches, sponsor scholarships to attend our full roster of tournaments,or sponsor travel to qualifying tournaments. We will need to think of other fundraising programs. SECTION 5: PRIOR FUNDING 1. If you received a Community Funding Grant in prior years, indicate the amounts for each year and describe how those funds were used: Not Applicable as this is the first time we are applying for grants. 2. If you received a Community Funding Grant last year: a. Please provide a line item breakdown of how the Community Funding Grant was used last year in the categories below. If a category is not applicable, put$0: .Admin Staff I. Materials/E ui ment I. Entertainment v. RoomNenue Rental . Other Professional Services . Other Total so b.Who was served by the grant last year? 1. Number of individuals total: ii. Number of Cupertino residents: iii. Particular community groups iv. Was the program/project/event available to the entire community/public or are there any eligibility offers? v. Was there a charge or fee for the program/project/event(if applicable)? vi.What outreach methods did your organization use to promote the program/projectievent(if applicable)? c.Was the program/projecUevent successful?Please indicate haw success was measured: 3.Please indicate any additional funding received last year from other sources and provide your financial statement if available: Attachments:Attach your financial statment,and any other helpful information about your project. MY-Speech Strategy antl Bggget 2021-22.gdf MV Saeecb Tax Return Documents 2019.pclf Program Manager Signature VP&Secretary Date Signed 01/31/2021 AIR SpeechMV d • - 2021-22 MVSD&MV 5 eecN Boo5R�5 -NO Nat OISM1l�utp 1 • rVista Speech Boosters + Monta Vista Speech Boasters Inc is a registered 501(c)(3)noriproflt • Tax JD ■ MA11ngAddress:2i840 M€Cielian Rd,Cupertino,CA 95014 r Erna;l� „�il,00s�ers[�g�nail cam MV Speech Boosters 8■ard of Ofredors Munta Vista High School Meera Natesan Pre$idenS&CEO,Speech 800sler5 Gamin Wong Head Speech Coach,MVH5 Rap Mah3linganj VP$secretary,Spaeth Boosters Mike-White Assistant Principal,MVH5 Nadathur Sundar CFO&Treasurer,Speech Boasters I *-"-R. MVSD&MV Speech BOOS ers- Do Not Distnbute Monta Vista Speech - 3 Year Strategy my 9oaa�n m ilm mesa rs n-ta embedded. ovmve tr:YtivyNa MR ewen.awunvv iwr mria mennxyn vxmp'nwnva teem rr µ%ennmvolr mvu wxvrawr memoersmM lmm ueW <mm El IVIV rp nenv, Wwarea mxvemners (-aoo deala nueere vwm�u �n led�vIddleed m l elide, ii zrnec Vembdublendlymmall le,bedded led,o",bellas aruumgxepra Fi qop n.I ueeM r mrr r nm I'll bell ul aewarmre line nuvree gwrunnin I"tell na daml rcp MA(Frld" r Veil bil ueded'ell Held bell xmux bell Fl r+wmw bellwngewn oat e pe�uoa%eeur MV50&MVS el liooll-Do Not Dls[rl0ue a°`eau xenuvwnmuruw 20%YOY Ninograpbio'. 2018-19:25 viu it and rest novice(new b Speech club) 2019-20 r G5 vaasily and 50 novice 2020-21: i,5 verdty end]5 novice Monta Vista Speech - 3 Year Strategy OmArm MV SoxM M Surex+- xmv�5,m mwnImM fun of N nWM �piN un�e 0.wmm tlwT,u#nN xxvw Mm fiNFm ffv WaA[.n wu 1 nw+m vYfineiln ~mmmwk, wtom ou gmWm w xnpM, M+bommwmq,s Ulm [m ,m'. suuc Nlolc. xnxj M MV50&MV Skech Boosters-Do Not DIWIt e ]D%YOY DO-NIMme metltlng• Strategy ItlMC MV Soeed.to..nw .....�.m,,........... MAN, urvMorw �Ma •..awaea deFeda 0,m.a mw:O"tv("')"eri:".e nxsPWNMft a mme,oo+7 e'men .... w ' .....w UN+.Mwwwe "...reo ...Pa..".. .......w...ou.e w.o....ew ...i.po c MV50&MV BVeen Bw4en-Oa Not BIAAbute Monta Vista Speech • (2019-22) Trim committee ewmnuun me mein(See mY$gem A" .?p) x019.zo tanked ern in G.Idol m Os by SOA 16 bumamenls artel(l l m.SonOnef ]8)awards molt ding 6 rau rnamem chammmehms Sxreepvakw anlwdkind)and xr4hem(61h)m 9 mmaring entries to CNSS4 Salads,3 mmidere to NEW hationa149 WaXI9ing magems So TuO%Merril ent of Champponrl $029R161rst temmerl r airmen attendee m inumwe eer lon0nel • as lnaWemgS wm uament cham9bsebbs otentiators in full level for upcoming S4nfoµ Berkeley and Smes/nal euadnenoumamem: Memeennb<rowing • 2M growth an Speech membership waravopear omme:peam wamtig and tournament;helped aumm memeerwb growth during Nvlo Labe 1p team of warner and bodem arl tea Cy member awe Inspire members M develop mewlerce In climb Speaking and power a aroN and vibrant teamculture • See MVSmeehoomm; M Weer IntervalIntervallmesrmen6/Eapeiuer tmaina. veneer ea Team growth romancers bMarepaNpfmrxvt MavtlmenY www-o l e AM29 of lrcrenrtwnr:aruNmg"MIC ,m2mom"rim,rummettamp,scomal and operational ehorrent ytts Monta Vista Speech - 3 Year Trend However: • Donation revenuer am grooving ata career pace • MAD seen In 2020-21 • mnenuiN room impact eapeaed m mna2 • hisfundbegavagnble)/am FUHSD SSapaux n n rmnryur nnarMabip cialirwh Muoass YOY eme rimauaog mpuryw IMwOanl mineMit as 1""0 SSLSY.W 51cre preach In donation der — re measures.possibly due to basis —n NS M: [Wm NIA SW ei.n RapW Lrowlb In membership pEtp Repair 010 berrexpeGed d0natlon revenues of$62560.00 in 2021-22: 1. Filed a simple linear repression model to 2019-20 and 2020-21 data to project a donation revenue of 51501A6 in 2D21-22. Y. Increased the amount by 2.055%to axavntf rr(hopefully)lessening CHID Improper heading into Fall 2022 FY 1 1 Financial ReportSi Aim Mtlymuna for 201e-26 AM fY Nlal9p Mom me,Spent gvFam had been nn¢ndrtWEy Wit coach tuition0l and numnl ceplalns ance 2017 Noose;gmmi mulaWm,Inte ume member donal • SNXinretalnM eamlgslromaavmulaletlmemaeraanadansxme and INfY301919 fY3ol Tam Am Few ml ewmlmbnhednnlme • Nr dreteved omentCfiver memberpar he 11re mans mmpam match • Mma Wumommxhmronnprta tp me xlma mIm ebskau lwm empemnmu cald,2mo aono) Ilmeredowemae, we o movement wn0 elemental em0ware Sa9Xbudcated butnospent: mvrrenm due mnorvrepmdvemon wnee allocated but not spent:co INK In Head wmmmpenmem.Hand Yearn emeem.rod:prams¢ e nxnasalmmmammmpawrmn.z Out ma,.,.mm¢avuua Awe onW awe mwwx halt menm,rs aK in OcaWOIXmtl • sXrnaM=lm 2mbyo x omm wk pins eone M[ImpatYabyl9V10:Wm¢raonIXpSW SWeaana HlfT%and mmxr9en NN50PNarinrab n most o.rormmm�n¢rreanman.ewe map¢mn¢m.m ma0nx DIe mmw.Igaxw}twrpmn.apcemdma.wax:Mwe.a araaeewma pr102o25aoasr»gangs General Note about Tourname d :(Explanation for Schedule O,lines 01 and 02 of the pY 2019-20 we return) As a service to our Speech community,MV Simal Roosters fadlitales loumament payments.The service is offered an a returned bass,is all funds mollecled from students are paid out to vendors with zero Income b Speech Boosters. Support members register are pay be Opponents via the pill wettest,and MV Speech Boosters collects these funds and pays be vendors at Rue eac wend(bumamenl organizers,hotels,airlines etc). For FY 2019 20.the following line items in the IRS 990-E2 form reflect Tournament Income and Expenses: Sohedule O:Supplemental Income From The blowing him Item shows all loumament income received via bbwomvenl payments hods Speech embers: 01:Tournament Income:U2497 The blbwing Six line items forgather encompass all fqumamen4mlafed expenses(payments to vendors) 02: Tournament $20615-(Tournament Involute for loml and bevel sumarrenle) Trauspotal §C051-Window;to ASU Fountainhead) Travel Meals: 612a-MeimbumerrenU to chaperones) Lodging: $16963-(Nobel charges for ASU and Berkeley marramants) Other Travel: I (SouterestAldlnes mandate brASU-utilized'.NIETOC-refunded as airline credit due to COVIO) Travel Expanses: i297-floeimburs0me06 W centuries) Total: $43250 Toumament Expenses: $45760 Note:Tournament expenses sliI exceeded bummww l income in 2019-20 of us W a variety of uIntonation cartatemospaincom related to travel humanness.For subsequent years we expend tournament inctrne and expenses to be almost equal,wit no not gain or loss to MV Speech Boasters. 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Onachlne and chaperoning eun.neramp 1M ve-9gRmw i4aB.1p SchabahlM ins-amraln .u2 ce9.m rowrommaud Madrid lmm urm Macho anrauwa,.... mrpn o.aAmweem, alarm charm. .maeammaa411 mvso 6 ov speech eoortere-oo Not oixlnbute Note: 1. Proposed allocat'lon 0$$13K grant In 2021-22 - Admin Stet.(26%5+12550+24]0=<1395)=$13,024-$3000=S10,0I Olhar(Scholarships):$3000=$3000 2.Since tuumaments do not yield any net inmme for MV Speeds Barbara,eve do not have a 7eumaments'One item in the program budget.See the Speaker Notes for Slide 8 bar addlgonal conbM. Short Form OMB No.1545-0047 Form 990-EZ Return of Organization Exempt From Income Tax 2019 Under section 501(c),527,or 4947(a)(1)of the Internal Revenue Code(except private foundations) ► Do not enter social security numbers on this form as it maybe made public. Open to Public Department of the Treasury Inspa6tion Internal Revenue Service ► Go to twww.frs.gov1Forrn990EZfor instructions and the latest Information. A For the 2019 calendar year,or tax year beginning 07-01 ,2019,and endin 06-30 ,2020 B Check if applicable: C Name of organization D Employer identification number ❑ Address change XONTA VISTA HIGH SCHOOL SPEECH BOOSTERS INC ❑ Name change Number and street(or P.O.box,if mail is not delivered to street address) ftoomisuite E Telephone number ❑ Initial return ❑ Final returniterminated 21840 14CCLELLAN ROAD ❑ Amended return [Cupertino, ity or town,state or province,country,and ZIP or foreign postal code F Group Exemption ❑ Application pending CA 95014 Number ► G Accounting Method: ❑% Cash Ll Accrual Other(specify) ► H Check► 0 if the organization is not I Wobsite: ► required to attach Schedule B J Tax-exempt status(check only one)-® 60i(c)(3) ❑501 c( ){ (insert no.) ❑ 4947(a)(1)or ❑527 (Form 990,990-EZ,or 990-PF). � K Form of organization: 0 Corporation ❑ Trust ❑ Association ❑ Other L Add lines 5b,6c,and 7b to line 9 to determine gross receipts. If gross receipts are$200,000 or more,or if total assets i Part 11,column(B) are$500,000 or more,file Form 990 instead of Form 990-EZ . I. $ 85,441 Part'I Revenue, Expenses, and Changes in Net Assets or Fund Balances(see the instructions for Part 1) Check if the organization used Schedule O to respond to any question in this Part I . . . . . . . . . . . . . . . . . . .❑x 1 Contributions,gifts,grants,and similar amounts received . . . . . . . . . . . . . . . . . . . . . . . . . . 1 42,175 2 Program service revenue Including governmentfees and contracts. . . . . . . . . . . . . . . . . . . . . . 2 3 Membershlp dues and assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 4 Investment income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 769 5a Gross amount from sale of assets other than inventory . . . . . . . . . . . . . 5a b Less;cost or other basis and sales expenses. . . . . . . . . . . . . . . > . . 5b c Gain or(loss)from sale of assets other than inventory(Subtract line 5b from line 5a) . . . . . . . . . . 5c 6 Gaming and fundraising events: a Gross income from gaming(attach Schedule G if greater than e $15,000) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6a b Gross income from fundraising events(not including $ of contributions from fundraising events reported on line 1)(attach Schedule G if the sum of such gross income and contributions exceeds$16,000) . . . . . . . . . 6b c Less:direct expenses from gaming and fundraising events . . . . . . . . 6c d Net income or(loss)from gaming and fundraising events(add lines 6a and 6b and subtract line 6c) . . . . . . . . . . . . . . . . . 6d 7a Gross sales of inventory,less returns and allowances. . . . . . . . . . . . . . 7a b Less:cost of goods sold. . . . . . . . . . . . . . . . . . . . . . . . . . . . 7b c Gross profit or(loss)from sales of Inventory(Subtract line 7b from line 7a). . . . . . . . . . . . . . . . . . 7c 8 Other revenue(describe in Schedule O) . . . . . . . . . . . . . . . . . . 8 42,497 9 Total revenue. Add lines 1,2,3,4,5c,6d,7c,and a .► 9 85,443. 10 Grants and similar amounts paid(list in Schedule O). . . . . . . . . . . . . . . . . . . . . . . . . . 10 11 Benefits paid to or for members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 i w 12 Salaries,other compensation,and employee benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 16,067 �i 13 Professional fees and other payments to Independent contractors . . . . . . . . . . . . . . . . . . . 13 14 Occupancy,rent,utilities,and maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 15 Printing,publications,postage,and shipping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 407 16 Other expenses(describe in Schedule O). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 54,168 3 17 Total expenses. Add lines 10through 16. .► 17 70,642 18 Excess or(deficit)for the year(Subtract line 17 from line 9) . . . . . . . . . . . . . . . . . . . . . . . . . 18 14,799 19 Net assets or fund balances at beginning of year(from line 27:column(A))(must agree with end-of-year figure reported on prior year's return). 19 24,253 z 20 Other changes in net assets or fund balances(explain in Schedule O). . . . . . . . . . . . . . . . . . . . 20 21 Net assets or fund balances at end of year.Combine lines 18 through 20. . . .0- 21 39,052 For Paperwork Reduction Act Notice,see the separate Instructions. Form 990-EZ(2019) EEA Form 990-EZ(2019) MONTA VISTA HIGH SCHOOL SPEECH BOOSTERS INC Page 2 Part 11 Balance Sheets (see the instructions for Part II) - Check if the organization used Schedule O to respond to any question in this Part II . .❑x (A)Beginning of year (B)End of year 22 Cash,savings,and investments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24,253 22 39,057 23 Land and buildings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 23 0 24 Other assets(describe In Schedule 0) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 24 0 25 Total assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24,253 25 39,057 26 Total liabilities(describe in Schedule O) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 26 5 27 Net assets orfund balances(line 27 of column 13 must agree with line 21). . 24,253 27 39,052 Part III. Statement of Program Service Accomplishments(see the instructions for Part 111) Expenses Check if the organization used Schedule.0 to respond to any question in this Part III . . . . . . .❑ (Required for section What is the organizations primary exempt purpose? HIGH SCHOOL SPEECH BOOSTER CLUB 501(c)(3)and 501(c)(4) Describe the organizations program service accomplishments for each of its three largest program services, organizations;optional for as measured by expenses.In a clear and concise manner,describe the services provided,the number of others.) persons benefited,and other relevant information for each program title. 28 HIGH SCHOOL SPEECH INTER .SCHOOL TOURNAMENT � 1 Grants $ ) If this amount includes foreign grants,check here . 0. ❑ 28a 0 ! 29 i Grants $ } If this amount includes foreign grants,check here . 6 ❑ 29a 30 (Grards $ If this amount includes foreign grants,check here . ► ❑ 30a 31 Other program services(describe in Schedule O) . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . Grants $ If this amount includes foreign grants,check here . 1► ❑ 31a 32 Total program service expenses add lines 28a through 31a). ► 32 0 Part 1) . List of Officers,Directors,Trustees,and Key Employees(list each one even if not compensated-seethe instructions for Part IV) Check if the organization used Schedule O to respond to any question in this Part IV , ,❑ (b) Average (c) Reportable (d) Health benefits, (a) Name and title hours per weak compensation contributions to employee (e) Estimated amount of (Forms W-211099-MISC) benefit plans,and other compensation devoted to position if not paid,enter.0-11 deferred owponsation Nadathur Sundar CHIEF FINANCIAL OFFICER 6.00 0 0 0 j MEHRA SRINIVASAN NATESAN CHIEF EXECUTIVE OFFICER 24.00 0 0 0 ] Rajeswari Mahalingam SECRETARY 8.50 0 0 0 EEA Form 990-EZ(2019) Form 990-EZ(2019) MONTA VISTA HIGH SCHOOL SPEECH BOOSTERS INC Page Part V Other Information (Note the Schedule A and personal benefit contract statement requirements in the instructions for Part V.)Check if the organization used Schedule O to respond to any question in this Part V . . ❑ Yes No 33 Did the organization engage in any signifcant activity not previously reported to the IRS?If"Yes,"provide a detailed description of each activity in Schedule O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 X 34 Were any significant changes made to the organizing or governing documents? If"Yes,"attach a conformed copy of the amended documents if they reflect a change to the organization's name.Otherwise,explain the change on Schedule O.See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 X 35 a Did the organization have unrelated business gross income of$1,000 or more during the year from business activities(such as those reported on lines 2,6a,and 7a,among others)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . 35a X b If"Yes,"to line 35a,has the organization filed a Form 990-T for the year?If"No,"provide an explanation in Schedule Q . . 35b c Was the organization a section 601(c)(4),601(c)(5),or 501(c)(6)organization subject to section 6033(e)notice, reporting,and proxy tax requirements during the year?if"Yes,"complete Schedule C,Part III. . . . . . . . . . . . . . . . . 35c X 36 Did the organization undergo a liquidation,dissolution,termination,or significant disposition of net assets during the year? If"Yes,"complete applicable parts of Schedule N. . . . . . . . . . . . . . . . . . . . . . . . . . 36 X 37 a Enter amount of political expenditures,direct or indirect,as described in the Instructions . . . . . . . ► 37a b Did the organization file Form 1120-POL for this year?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37b X 38 a Did the organization borrow from,or make any loans to,any officer,director,trustee,or key employee or were any such loans made in a prior year and still outstanding at the end of the tax year covered by this return?. . . . . . . . . . . 38a X b If"Yes,"complete Schedule L,Part II and enter the total amount involved. . . . . . . . . . . . . . . . 38b 39 Section 501(c)(7)organizations, Enter; a Initiation fees and capital contributions included on line 9. . . . . . . . . . . . . . . . . . . . . . . 39a b Gross receipts,included on line 9,for public use of club facilities. . . . . . . . . . . . . . . . . . . . 39b 40 a Section 501(c)(3)organizations. Enter amount of tax imposed on the organization during the year under: sect€on 4911 ► ;section 4912 ► ;section 4955 ► b Section 501(c)(3),501(c)(4),and 501(c)(29)organizations.Did the organization engage in any section 4958 excess benefit transaction during the year,or did it engage in an excess benefit transaction in a prior year that has not been reported on any of its prior Forms 990 or 990-EZ?If"Yes,"complete Schedule L,Part I.. . . . . . . . . . . . 40b X c Section 501(c)(3),601(c)(4),and 501(c)(29)organizations.Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 4955,and 4958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ► d Section 501(c)(3),501(c)(4),and 501(c)(29)organization.Enter amount of tax on line 40c reimbursed by the organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ► e All organizations.At any time during the tax year,was file organization a party to a prohibited tax shelter transaction?If"Yes,"complete Form 8886-T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40e X 41 List the states with which a copy of this return is filed ► 42 a The organization's books are in care of ► Nadat;hur Sundar Telephone no. 0- Located at Cupertino, CA ZIP+ 4 ► 95014 b At any time during the calendar year,did the organization have an interest in or a signature or other authority over Yes No a financial account in a foreign country(such as a bank account,securities account,or other financial account)? . . . . . . . . .. 42b X If"Yes,"enter the name of the foreign country ► i See the instructions for exceptions and filing requirements for FInCEN Form 114,Report of Foreign Bank and 1 Financial Accounts(FBAR). c At arry time during the calendar year,did the organization maintain an office outside the United States2 . . . .. . . . . . . . . . 42c X If"Yes,"enter the name of the foreign country ► I 43 Section 4947(a)(1)nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041-Check hero. . . . . . . . . . . . ► and enter the amount of tax-exempt interest received or accrued during the tax year. . . . . . . . . . . . . . . . . . ► 43 Yes No 44 a Did the organization maintain any donor advised funds during the year?If"Yes,"Form 990 must be completed instead of Form 990-EZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44a X b Did the organization operate one or more hospital facilities during the year?If"Yes,"Form 990 must be completed instead of Form 990-EZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44b X c Did the organization receive any payments for indoor tanning services during the year? . . . . . . . . . . . . . . . . . . . . . 44c X d If"Yes,"to line 44c,has the organization filed a Form 720 to report these payments?if"No,"provide an explanation in Schedule O. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44d 45 a Did the organization have a controlled entity within the meaning of section 612(b)(13)? . . . . . . . . . . . . . . . . . . . . 45a X b Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)?If"Yes,"Form 990 and Schedule R may need to be completed instead of Form 990-EZ.See instruction 45b X FFA Form 990-EZ(2019) Form 990-EZ(2019) MONTA VISTA HIGH SCHOOL SPEECH BOOSTERS INC � Page Yes No 46 Did the organization engage,directly or indirectly,in political campaign activities on behalf of or in opposition to candidates for public office? If"Yes,"complete Schedule C,Part 1 46 X JPArt.WJ Section 501(c)(3) Organizations Only All section 501(c)(3)organizations must answer questions 47 49b and 52, and complete the tables for lines 50 and 51. Check if the or anization used Schedule O to respond to any question in this Part VI . . . . . . . . . . . . . .❑ Yes No 47 Did the organization engage In lobbying activities or have a section 501(h)election in effect during the tax year?If"Yes,"complete Schedule C,Part 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 X 48 Is the organization a school as described in section 170(b)(1)(A)(ii)?If"Yes,"complete Schedule E. . . . . . . . . . . . . . . 48 X 49a Did the organization make any transfers to an exempt non-charitable related organization? . . . . . . . . . . . . . . . . . . . 49a X b If"Yes,"was the related organization a section 527 organization? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49b 50 Complete this table for the organization's five highest compensated employees(other than officers,directors,trustees and key ant loyees)who each received more than$100,000 of compensation from the organization. If there is none,enter"None." (b)Average (c) Reportable (d) Health benefits, contributions to empioyae (a) Estimated amount of (a) Name and title of each employee hours per week compensation benefit plans,and deferred other compensation devoted to position (Forms W-211099-MISC) compensatfon i NONE f Total number of other employees paid over$100,000 . . . . . . . ► 51 Complete this table for the organizations five highest compensated independent contractors who each received more than $100,000 of compensation from the organization. If there is none,enter"None." (a)Name and business address of each independent contractor (b)Type of service (a) Compensation NONE i i 9{� 1 d Total number of other independent contractors each receiving over$100,000. . . . . .► 52 Did the organization complete Schedule A?Note:All section 501(c)(3)organizations must attach a completed Schedule A ► © Yes ❑ No Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,it is true,correct,and complete. Declaration of preparer(other than officer)is based on all information of which preparer has any knowledge. Nadathur Sundar Sign Signature of officer Date Here, Nadathur Sundar, CHIEF FINANCIAL OFFICER Type or print name and title PrintlType preparees name Preparer's signature Date Check ❑ if PTIN Paid 1 0-21-2020 self-employed Preparer Firm'sname ► S1n a ax and Financial Service's Firm'sEIN 0- USG Only Ftrm'saddress ► Santa Clara CA 95051 Phone no. May the IRS discuss this return with the preparer shown above? See Instructions . ► © Yes ❑ No EEA Form 990-EZ(2019) SCHEDULE A 2019 y Public Charity Status and Public Support OMB No.1545-0047 (Form 990 or 990-EZ) Complete if the organization is a section 501(c)(3)organization or a section 4947(a)(1)nonexempt charitable tru t. 20 1 9 Department of the Treasury Attach to Form 990 or Form 990-EZ. Open tapublic Internal Revenue Service m Go to www.1r5.gov/Form990 for instructions and the latest Information. Inspection. Name of the organization Employer Identification number MONT,A. VISTA HIGH SCHOOL SPEECH BOOSTERS INC Part I I Reason for Public Charity Status All or anizations must complete this art. See instructions. The organization is not a private foundation because it is:(For lines 1 through 12,check only one box.) 1 ❑ A church,convention of churches,or association of churches described in section 170(b)(1)(A)(i). 2 ❑ A school described in section 170(b)(1)(A)(ii).(Attach Schedule E(Form 990 or 990-EZ).) 3 ❑ A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(111). 4 ❑ A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(Iii).Enter the hospital's name,city,and state: 5 ❑ An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv).(Complete Part Il.) 6 ❑ Afederal,state,or local government or governmental unit described in section 170(b)(1)(A)(v). 7 ❑ An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vl).(Complete Part fl.) S ❑ A community trust described in section 170(b)(1)(A)(A).(Complete Part 11.) 9 ❑ An agricultural research organization described in section 170(b)(1)(A)(ix)operated in conjunction with a land-grant college or university or a non-land-grant college of agriculture(see instructions).Enter the name,city,and state of the college or university: 10 ❑X An organization that normally receives:(1)more than 33 113%of its support from contributions,membership fees,and gross receipts from activities related to its exempt functions-subject to certain exceptions,and(2)no more than 33 1/3%of its i support from gross investment income and unrelated business taxable income(less section 511 tax)from businesses j acquired by the organization after June 30,1975.See section 509(a)(2).(Complete Part III.) 11 ❑ An organization organized and operated exclusively to test for public safety.See section 509(a)(4). 12 ❑ An organization organized and operated exclusively for the benefit of,to perform the functions of,or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1)or section 509(a)(2).See section 509(a)(3). Check the box in lines 12a through 12d that describes the type of supporting organization and complete lines 12e,12f,and 12g. a ❑ Type 1.A supporting organization operated,supervised,or controlled by its supported organization(s),typically by giving the supported organization(s)the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization.You must complete Part IV,Sections A and B. b ❑ Type 11,A supporting organization supervised or controlled in connection with its supported organization(s),by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s),You must complete Part IV,Sections A and C. c ❑ Type III functionally integrated.A supporting organization operated in connection with,and functionally integrated with, its supported organization(s)(see instructions).You must complete Part IV,Sections A,D,and E. d ❑ Type Ill non-functionally integrated.A supporting organization operated in connection with its supported organization(s) that is not functionally integrated.The organization generally must satisfy a distribution requirement and an attentiveness requirement(see instructions).You must complete Part IV,Sections A and D,and Part V. 1 e ❑ Check this box if the organization received a written determination from the IRS that it is a Type I,Type II,Type III II functionally integrated,or Type III non-functionally integrated supporting organization. f Enter the number of supported organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . g Provide the following information abouk the supported organization(s). (1)Name of supported organization pi)EIN (III)Type of organization (IV)Is the organization (v)Amount of monetary (vi)Amount of (described on lines 1-10 listed in your governing support(see other support(see above(see Instructions)) document? Instructions) instructions) Yes No (A) (13) (C) (D) (E) Total For Paperwork Reduction Act Notice,see the Instructions for Form 990 or 990-EZ. schedule A(Form 990 or 990-Ez)2019 EEA Schedule A(rurrn990or990-EZ)2019 MONTA VISTA HIGH SCHOOL SPEECH BOOSTERS INC Pago2 Part,ll I Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part 111. If the organization fails to qualify under the tests listed below, please complete Part III. Section A. Public Support Calendar year(or fiscal year beginning in)P. a 2015 b 2016 c 2017 d 2018 a 2019 f Total 1 Gifts, grants, contributions, and membership fees received. (Do not include any"unusual grants.") . . . . . . . 2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf 3 The value of services or facilities furnished by a governmental unit to the organization without charge . . . . . . . 4 Total.Add lines 1 through 3 . . . . . . . 5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization)included on line 1 that exceeds 2%of the amount shown on line 11,column (f) . . . . . . . 6 Public support.Subtract line 5 from line 4 Section D. Total Support Calendar year(or fiscal year beginning in)► a 2015 b 2016 c 2017 d 2018 a 2019 Total 7 Amounts from line 4. . . . . . . . . . . . B. Gross income from interest, dividends, payments received on securities loans, .rents, royalties' and income from similar sources j 9 Net income from unrelated business activities,whether or not the business is regularly carried on . . . . . . . . . . . 10 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) 11 Total support.Add lines 7 through 10. . 12 Gross receipts from related activities,etc. (see instructions) . . . . . . . . . . . . . . . . . . . . . 12 13 First five years.'If the Form 990 is for the organization's first, second,third,fourth,or fifth tax year as a section 501(c)(3) _ organization, check this box and stop here .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ® ❑ Section C. Com utation of Public Support Percentage 14 Public support percentage for 2019(line 6, column(f)divided byline 11, column (f)). . . . . . . . . 14 % 15 Public support percentage from 2018 ScheduleA, Part 11, line 14 15 1 % 16a 33113%support test-2019. if the organization did not check the box on line 13, and line 14 is 33 113%or more, check this box and stop here.The organization qualifies as a publicly supported organization . . . . . . . . . . . . . . . . : . . . . . ► ❑ b 33113% support test-2018.-If the organization did not check a box on line 13 or 166,and line 15 is 33 113%or more, check this box and stop here.The organization qualifies as a publicly supported organization . . . . . . . . . . . . . . . . . . . . ► ❑ 17a 10%-facts-and-circumstances test.2019. If the organization did not check a box on line 13, 16a, or 16b,and line 14 is 10%or more, and if the organization meets the"facts-and-circumstances"test, check this box and stop here. Explain in Part V1 how the organization meets the"facts-and-circumstances"test. The organization qualifies as a publicly supported organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ► ❑ b 10%-facts-and-circumstances test-201 B. If the organization did not check a box on line 13, 16a, 16b,or 17a,and line 15 is 10%or more,and if the organization meets the"facts-and-circumstances"test, check this box and stop here. Explain in Part VI how the organization meets the"facts-and-circumstances"test. The organization qualifies as a publicly supported organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ► ❑ 18 Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a,or 17b, check this box and see instructions r ❑ EEA ",""'.. '-- Schedule A(Farm 990 or 990-EZ)2019 Schedule A(Form 900 or 990-EZ)2019 MONTA VISTA HIGH SCHOOL SPEECH BOOSTERS INC Page 3 Part', Wl Support Schedule for Organizations Described in Section 609(a)(2) (Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part II.. If the organization fails to qualify under the tests listed below, please complete Part 11.) Section A. Public Support Calendar year(or fiscal year beginning In)► a 2015 b 2016 c 2017 d 2018 a 2019 Total 1 Gifts,grants,contributions,and membership fees received..(Do not Include any"unusual grants.") 6,245 42,175 48,420 2 Gross receipts from admissions,merchandise sold or services performed,or facilities furnished in any activity that is related to'the organization's tax-exempt purpose . . . . . . 3 Gross receipts from activities that are not an unrelated trade or business under section 513, 4 Tax revenues levied for the organization's benefit and either paid.to or expended on its behalf . . . . . . . . 5 The value of services or facilities furnished by a governmental unit to the organization without charge . . . . . . . 6 Total.Add lines 1 through 5 6,245 42,175 48,420 7a Amounts included on lines 1,2,and 3 received from disqualified persons . . . b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of$5,000 or 1%of the amount on line 13 for the year c Add lines.7a and 7b . . . . . . . . . 8 Public support. (Subtract line 7c from line 6,) . . . . . . . . . . . . . . . . . . 48,420 Section B. Total Support Calendar year(.or fiscal year beginning in)► a 2015 b 2016 c 2017 d 2018 a 2019 Total 9 Amounts from line 6 . . . . . . . . . . . 6,245 42,175 48,420 j 10a Gross income from Interest,dividends, I payments received on securities loans,rents, royalties,and income from similar sources 769 769 b 'Unrelated business taxable income (less section 511 taxes)from businesses acquired after June 30, 1975 . . . . . . c Add lines 10a and 10b . . . . . . . . 76 769 11 Net income from unrelated business activities not included in.line 10b,whether or not the business is regularly carried on 12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) . . . . . . . . . . . . 48,158 42,497 90,655 13 Total support. (Add lines 9, 10c, 11, and 1.2.) . . . . . . . . . . . . . . 54,4D3 85,44 139,944 14 First five years.If the Form 990 is for the organization's first,second,third,fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here__. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . ► ❑x Section C. Computation of Public Support Percentage _ 15 Public support percentage for 2019(line 8, column (f), divided by line 13,column (f)) . . . . . . . . . 15 % 16 Public support percentage from 2018 Schedule A, Part III, line 15 . . . . . . . . . . . . . 16 % Section D. Computation of Investment Income Percentage 17 Investment income percentage for 2019(line 10c,column (f), divided by line 13,column(f)). . . . . . 17 % 18 Investment income percentage from 2018 Schedule A, Part III, line 17. . . . . . . . . . . . . . . . . . 18 % 19a 33113%support tests-2019. If the organization did not check the box on line 14,and line 15 is more than 33 113%, and line 17 is not more than 33 113%,check this box and stop here.The organization qualifies as a publicly supported organization . . ► ❑ b 33113%support tests-2018. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33113%, and line 18 is not more than 33 113%,check this box and stop here.The organization qualifies as a publicly supported organization ► ❑ 20 Private foundation, If the organization did not check a box on line 14, 19a,or 19b, check this box and see instructions. . . . ► ❑ SEA Schedule A(Form 990 or 990-EZ)2019 SCHEDULE O Supplemental Information to Form 990 or 990-EZ OMB No.1545-0047 (Form 990 or 990-EZ) Complete to provide information for responses to specific questions on2019 Form 990 or 990-EZ or to provide any additional information. Department of the Treasury D Attach to Form 990 or 990-EZ. Open o PUbHe Internal Revenue Service ► Go to wwwJrs.gov1Form990 for the latest information. - ..Ins eCtion. Name of the organization Employer i&MMcatlon number MONTA VISTA HIGH SCHOOL SPEECH BOOSTERS INC 01.. Description of other revenue (Part I, line 8) Description Amount TOURNAMENT INCOME 42,497 02. Description of other expenses (Part I, line 16) Description Amount E ACCOUNTINQ 1,243 i TAX PREPARATION 460 i TRANSPORTATION 4,061 TRAVEL MEALS 124 LODGING 16,963 WEB HOSTING 611 INSURANCE (245) BANK FEES 39 STRIPE FEES 2,034 ACCOUNTING SOFTWARE 330 i LEAGUE MEMBERSHIP 780 E SPEECH CURRICULUM 120 t 1 TOURNAMENT 20-,615 h ENTERTAINMENT 1,071 SPECIAL EVENTS 673 VENUE/DECOR EXPENSE 28 FUNDRAISING EXPENSES 14 SUPPLIES 1,601 LEGAL 25 For Paperwork Reduction Act Notice,see the Instructions for Form 990 or 990-EZ. schedule o(Form 990 or 990-EZ)12019) EEA Schedule O(Form 990 or 990-EZ)(2010) Page 2 Name of the organization Employer identification number MONTA VISTA HIGH SCHOOL SPEECH BOOSTERS INC LEGAL SOFTWARE 108 OTHER-TRAVEL EXPENSE 1,700 OTHER PROFESSIONAL SERVICES 200 PROJECT TRACKING SOFTWARE 682 BUSINESS ENABLEMENT SOFTWARE 644 TRAVEL EXPENSES 287 03. Description of total liabilities (Part II, line 26) Category Beginning of Year End of Year CREDIT CARD 0 S EEA Schedule 0(Form 990 or 990•EZ)(2019) IRS e-file Signature Authorization OMB No.1546-1878 Form 8879-EO for an Exempt Organization For calendar year 2019,or fiscal year beginning 07-01-2 019 and ending 0 6-•3 0-'2 02 0 Department of the Treasury ► Do not send to the IRS.Keep for your records. 2019 Internal Revenue Service ► Go to wwwJrs,gov1Form8879E0 for the latest Information. Name of exempt organization Employer Identification number MONTA VISTA HIGH SCHOOL SPEECH BOOSTERS INC Name and title of officer Nadathur Sundar, CHIEF FINANCIAL OFFICER Part'I. Type of Return and Return Information (Whole Dollars Only) Check the box for the return for which you are using this Form 8879-EO and enter the applicable amount;if any,from the return.If you check the box on line 1 a,2a,3a,4a,or 5a,below,and the amount on that line for the return being filed with this form was blank,then leave line 1b,2b,3b,4b,or 5b,whichever is applicable,blank(do not enter-()-).But,if you entered-0-on the return,then enter-0-on the applicable line below.Do not complete more than one line in Part I. I Farm 990 check here ► ❑ b Total revenue,if any(Form 990,Part Vill,column(A),line 12) . . . . . . , . . . . 1b 2a Form 990-EZ check here ► © b Total revenue,if any(Farm 990-EZ;line 9) . . . . . . . . . . . . . . . . . . 2b 85,441 3a Form 1120-POL check here ► ❑ b Total tax(Form 1120-POL,line 22) . . . . . . . . . . . . . 3b 4a Form 990-PF check here 0- ❑ b Tax based on investment Income(Form 990-PF,Part VI,line 5) . . . . . . . 4b 5a Farm 8868 check here ►❑ b Balance.Due(Form 8868,line 3c) . . . . . . . . . . . . . . . . . . . 5b F-P-4r-t—IIJ Declaration and Signature Authorization of Officer Under penalties of perjury,I declare that I am an officer Of the above organization and that I have examined a copy of the organization's 2019 electronic return and accompanying schedules and statements and to the best of my knowledge and belief,they are true,correct,and complete.I further declare that the amount in Part I above is the amount shown on the copy of the organization's electronic return. I consent to allow my intermediate service provider,transmitter,or electronic return originator(ERO) to send the organization's return to the IRS and to receive from the IRS(a)an acknowledgement of receipt or reason for rejection of the transmission,(b)the reason for any delay in processing the return or refund,and(c)the date of any refund.If applicable, authorize the U.S.Treasury and its designated Financial Agent to initiate an electronic funds withdrawal(direct debit)entrry to the financial insltution account indicated in the tax preparation software for payment of the organization's federal taxes owed on this return,and the financial institution to debit the entry to this acoounL To revoke a payment,I must contact the U.S.Treasury Financial Agent at 1-888-353-4537 no later than 2 business days prior to the payment(settlement)date.I also authorize the financial Institutions involved in the processing of the electronic payment of taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment.I have selected a personal identification number(PIN)as my signature for the organization's electronic return and,if applicable,the organizatlon's consent to electronic funds withdrawal. Officer's PIN.check one box only I authorize 5inga Tax and Financial Ser to enter my PIN ) as my signature ERO firm name Enter five numbers,but it - do not enter all zeros on the organization's tax year 2019 electronically filed return.If I have indicated within this return that a copy of the return is being filed with a state agency(Ies)regulating charities as part of the IRS Fed/State program,I also authorize the aforementioned ERO to enter my PIN on the return's disclosure consent screen. 0 As an officer of the organization,I will enter my PIN as my signature on the organization's tax year 2019 electronically filed retum. If I have indicated within this return that a copy of the return is being filed with a state agency(ies)regulating charities as part of the IRS Fed/State program,I will enter my PIN on the return's disclosure consent screen. Officer's signature ► - Date ► 09-28-2020 Partlll` Certification and Authentication ERO's EFINlPIN.Enter your six-digit electronic filing identification number(EFIN)followed by your five-digit self-selected PIN. Do not enter all zeros I certify that the above numeric entry is my PIN,which is my signature on the 2019 electronically filed return for the organization indicated above,I confirm that I am submitting this return In accordance with the requirements of Pub.4163,Modernized a-File(MeF) Information for Authorized IRS a-file Providers for Business Returns. ERO'ssignature ► Date ► 10-21-2020 ERO Must Retain This Form -See Instructions Do Not Submit This Form to the IRS Unless Requested To Do So For Paperwork Reduction Act Notice,see instructions. Form 8879-EO (2019) EEA TAXABLE YEAR California Exempt Organization FORM. 2019 Annual Information Return 199 Calendar Year 2019 or fiscal year beginning(rftmldd/yyyy) 0 7--01--2 019 and ending(mmlddlyyyy) 0 6—3 0--2 02 0 Corporation/Organization name California corporation number MONTA VISTA HIGH SCHOOL SPEECH BOOSTERS INC 4042901 Additional information,see instructions. FEIN Street address(suite or mom) PMB no. 21840 MCCLELLAN ROAD City Stale Zip code CUPERTINO. CA 95014 Foreign country name Foreign provincelstalelcounly Foreign postal code A First Return • • • • • • • • • • • • • • • • • • • • • • ❑ Yes ❑ No J If exempt under R&TC Section 23701d,has the organization B Amended Return • • • • • • • • • . • • • • • • • • •❑ Yes ❑ No engaged in political activities?See instructions • • • • • • •❑ Yes ❑ No C IRC Section 4941(a)(1)trust • • • • . • • • • • • • 0 Yes ❑ No K Is the organization exempt under R&TC Section 23701g? • • • • • • •❑ Yes ❑ No A Final Information Return? If"Yes,"enter the gross receipts from nonmember sources $ •❑•Dissolved ❑ Surrendered(Withdrawn) ❑ Merged1Reorganlzed L If organization is a public charity exempt under R&TC Enter date:(mmlddlyyyy) • Section 23701d and meets the tiling fee exception, E Check accounting method: MM Cash (2) ❑ Accrual (3) ❑ Other check box.No filing fee Is required . • • • . • • • • • • • . • •❑ F Federal return filed? (1) •❑ 990T (2) •❑ 99OPF (3) •❑ Sch H(990) M' Is the organization a Limited Liability Company? . • • • • . . •❑ Yes ❑ No MIN Other 990 series N Did the organization file Form 100 or Form 109 to report G Is this a group filing?See Instructions • . • . . • . . •❑ Yes ❑ No taxable Income? . • . • • • • . • • . • • . • . . • • • . •❑ Yes ❑ No H Is this organization in a group exemption • • • • • • • • r ❑ Yes ❑ No O Is the organization under audit by the IRS of has the IRS If"Yes,"what is the parent's name? - audited In a prior year? • • • • • • • • • . • • • • • • • •❑ Yes ❑ No P Is federal Form 102311024 pending? • • • . • • • ❑ Yes FIND Did the organization have any changes to its guidelines Date filed with IRS not reported to the FTB?See instructions • • • • • • • • • • •❑.Yes ❑ No Part I Complete Pad I unless not required to file this form, See General Information B and C. 1 Gross sales or receipts from other sources. From Side 2,Part ll,line 8 • • • • • • • • • • • • • • • • • • • . • 1 00 2 Gross dues and assessments from members and affiliates • • • • • • . • • • • • , • • • • . . . . . . . . . . . . O 2 00 Receipts 3 Grass contributions,gilts,grants,and similar amounts received • • • = • • . . . • • • • • • • • • • • • . • . • . . • 3 00 and Rovenuee 4 Total gross receipts for filing mqulremenFtest. Add line 1 through fine 3. This line must be completed.If the result is less then$50,000,see General Information B • . . • . • • • • • • • • • • • • • 4 0 00 5 Cost of goads sold• . • . • • • • • • • • • • . . . . . . . . . . . . . . . • 5 QQ 9 i 6 Cost or other basis,and sales expenses of assets sold �• - • 6 00 7 Total casts.Add line 5 and line 6 . . . . . . . . • • • • • • • • • • • • • • • • • • • • • • • . . . . . . . . . 7 00 6 Total gross Income.Subtract line 7 from line 4• . • • • • • • • • . • • • • . • • • • • • • • • • • • • • • • • • • • 8 00 1 i 9 Total expenses and disbursements. From Side 2,Part ll,line 18 • • • • • • . • • • . . . . . • . • . . . . . . . . • g 00 Expense 10 Excess of receipts over expenses and disbursements. Subtract line 9 from line 8 • . . • . . • • • • • • • 10 00 r 11 Total payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • 11 00 12 Use tax.See General Information K • • • • • • • • • • . . . • • . • • • • • • • • • • • • • • • • . . • 12 00 Filing Foe 13 Payments balance.If line 11 Is more than line 12,subtract line 12 from line 71 • • • . . • . . . • • • • • • • • • • • • • • tl 13 00 14 Use tax balance.If line 12 is more than line 11,subtract line 11 from line 12 • . . • • • . • • • • • • • . . O 14 00 15 Filing fee$10 or$25.See General Information F• • • . • • . • • • • • • • • • • • • • • • • • . . • . . . • • • • . 15 00 1 16 Penalties and interest.See General Information J. • • . . . . . . • . . . . . . . . . . . . . . . . . 16 00 11 Balance due.Add line 12,line 15,and line 16.Then subtract line 11 from the result • • • • • • , • • • • • O 17 00 Under penalties of perjury.I declare that I have examined this return,including accompanying schedules and statements,and to the hest of my knowledge and belief,it Is Sign true,correct,and complete. DedaratiOn of preparer(other than taxpayer)Is based on all information of which preparer has any knowledge. Here Title Date •Telephone Signature — ofoffic8r ONADATHUR SUNDAR HIEF FINANCI 9�28�2020 Preparers Date Check if self- •PTIN signature 0 21 2'0 2 0 employed > ❑ Paid Preparer's Firm's name(or yours, •Firm's FEIN Use Only if self-employed) ► SINGA TAX AND FINANCIAL SERVICES and address - *Telephone SANTA CLARA, CA 95051 May the FTB discuss this return with the preparer shown above? See instructions • • • • • • • • • . • • • • • • . • • • • •® Yes ❑ No w l Farm 199 2019 Side 1 Part II Organizations with gross receipts of more than$50,000 and private foundations regardless of amount of gross receipts-complete Part II or furnish substitute information. 1 Gross sales or receipts from all business activities.See instructions • • . . . • • . . . . . . • . . • ® 1 00 2 Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • 2 00 3 Dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • 3 00 Receipts from 4 Gross rents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • 4 00 #r other 5 Gross royalties • • • • . • • • • • • 5 00 Sources 6 Gross amount received from sale of assets(See Instructions) • • • • • • • • • • • • . • • • • • • • + 6 00 7 Other income.Attach schedule • • . • • • • • • • • . • • • • • • • • • . . • • • • • . • . . • • • 7 00 8 Total gross sates or receipts from other sources.Add line 1 through line 7.Enter here and on Side 1,Part I,line 1. • • • • 8 00' 9 Contributions,gifts,grants,and similar amounts paid.Attach schedule . . • . . . • • . . • • . • • + 9 00 10 Disbursements to or for members • • • • • . • • • • • • • • • • • • • • • . • • • • • • • . . • . + 10 00 11 Compensation of officers,directors,and trustees.Attach schedule • • • • • • • • • • • • • • • • • • 11 00 12 Other salaries and wages • • • • . . • • • . . . . • . • • • • . • • • • • . . . . • . . . . . . . • 12 00 Expenses 13 Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • 13 00 and Disburse- 14 Taxes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • 14 00 1 Monts 15 Rents. . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • 15 00 { 16 Depreciation and depletion(See instructions) • . . . • . . . • . . . . • . . • . . . • • . . • . . . • 16 00 l 17 Other Expenses and Disbursements.Attach schedule • • • • . . . • . . . • • • • • . • • • • . . • 17 00 18 Total expenses and disbursements.Add line 9 through line 17.Enter here and on Side 1,Part 1,line 9 . . 18 00 i Schedule L Balance Sheet Beginning of taxable year End of taxable year Assets (a) (b) (c) (d) 1 Cash. . . . . . . .. . . . . • 2 Net accounts receivable • • . • • • • • • • • • 3 Net notes receivable • • •• • • • 4 Inventories• • • • • • • • . • • • • • • • • 5 Federal and state government obligations • • _ 6 Investments in other bonds • 7 Investments in stock • • • • • • • • . . • • 8 Mortgage loans • _ 9 Other investments.Attach schedule • • • • • • 10 a Depreciable assets • • . • • • b Less accumulated depreciation • • • • • • 11 Land. . . . . . . . . . . . . . . . . . . . • 12 Other assets.Attach schedule • • • . • • 13 Total assets . . . . . . . . . . . . . Liabilities and net worth 14 Accounts payable . . • . . • • • • . . • • + 15 Contributions,gifts,or grants payable • 16 Bonds and notes payable• • • • • • • • • • . • 17 Mortgages payable. . . . . . . . . . . . . . • 18 Other liabilities.Attach schedule 19 Capital stock or principal fund • • • . • • • • • 20 Paid-in or capital surplus.Attach reconciliation • 21 Retained earnings or income fund • 22 Total liabilities and net worth • . • . Schedule M-1 Reconciliation of income per books with income per return Vo not complete this schedule if the amount on Schedule L,line 13,column(d),is less than$50,000 1 Net income per books . . . . . • . . . • • • . • 7 Income recorded on books this year 2 Federal income tax . . . . • • • • • • • • . • • • not included in this return.Attach schedule • 3 Excess of capital losses over capital gains • • • • 8 Deductions in this return not charged 4 Income not recorded on books this year. against book income this year. Attach schedule • • • • • . • • • • • • • • • • • Attach schedule • • • 5 Expenses recorded on books this year not 9 Total.Add line 7 and line 8 • • • • • . . deducted in this return.Attach schedule • • • • • 10 Net income per return. 6 Total.Add line 1 through line 5 • • • • • • • • • Subtract line 9 from line 6 • • • . . . Side 2 Form 199 2019 043 Date Accepted DO NOT MAIL.THIS FORM TO FTB TAXABLE YEAR California a-tile Return Authorization for FORM 2019 Exempt Organizations 8453-EO Exempt Organization name Identifying number MONTA VISTA HIGH SCHOOL SPEECH BOOS Part 1 Electronic Return Information (whole dollars only) i Total gross receipts(Form 199,line 4) • • • • . . . . . . . . . . . . . . . o . . . . . . . . . . . . . 1 2 Total gross income(Form 199,line 8) • • • . • . . • • • • • • . . • • • • • • • • • • • • . . . . . . . . . 2 3 Total expenses and disbursements(Form 199,Line 9) . . • . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Part II Settle Your Account Electronically for Taxable Year 2019 4❑ . Electronic funds withdrawal 4a Amount 4b Withdrawal date(mmlddlyyyy) Part III Banking Information(Have you verified the exempt organization's banking information?) 5 Routing number 6 Account number 7 Type of account: ❑ Checking ❑ Savings Part IV Declaration of Officer authorize the exempt organization's account to be settled as designated in Part It.If I check Part 11,Box 4,1 authorize an electronic funds withdrawal for the amount listed on line 4a. Under penalties of perjury,I declare that I am an officer of the above exempt organization and that the information I provided to my electronic return originator (ERO),transmitter,or intermediate service provider and the amounts in Part I above agree with the amounts on the corresponding lines of the exempt organization's 2019 California electronic return.To the best of my knowledge and belief,the exempt organization's return is true,correct,and complete.if the exempt organization Is filing a balance due return,I understand that if the Franchise Tax Board(FTt3)does not receive full and timely payment of the exempt organization's fee liability,tha exempt organization will remain liable for the fee liability and all applicable interest and penalties.I authorize the exempt organization return and accompanying schedules and statements be transmitted to the FTB by the ERO,transmitter,or intermediate service provider.If tho processing of the exempt organization's return or refund is delayed,I authorize the FTB to disclose to the ERO or intermediate service provider the reason(s)for the delay. Sign ® 09-28-2020 ®CHIEF FINANCIAL OFFICER . Here Signature of officer Date Title Part V Declaration of Electronic Return Originator(ERO)and Pald Preparer.See instructions. I declere that I have reviewed the above exempt organization's return and that the entries on farm FTB 8453-EO are complete and correct to the best of my knowledge.(If I am only an intermediate service provider,I understand that I am.not responsible for reviewing the exempt organization's return.I declare, however,that form FTB 8453-EO accurately reflects the data on the return.)I have obtained the organization officer's signature on form FTB 8453-EO before transmitting this return to the FTB;I have provided the organization officer with a copy of all forms and information that I will file with the FTB,and I have followed all other requirements described In FTB Pub:1345.2019 Handbook for Authorized a-file Providers.I will keep form FTB 8453-EO on file for four years from the due date of the return or four years from the date the exempt organization return is filed,whichever is later.and I will make a copy available to the FTB upon request.If I am also the paid preparer,under penalties of perjury,I declare that I have examined the above exempt organization's return and accompanying schedules and statements,and to the best of my knowledge and belief,they are true,correct,and complete.I make this declaration based on all information,of which I have knowledge. Date Check.if Check ERO's PTIN ERO's- also paid If self- ERO signature ® preparer ® employed ❑ Must Firm's FEIN Sign Ifsm'a name mployeryeurs SINGA TAX AND FINANCIAL SERVICES g If self-employed) and address ZIP code SANTA CLARA CA 195051 Under penalties of perjury,I declare that 1 have examined the above organization's return and accompanying schedules and statements,and to the best of my knowledge and belief,they are true,correct.and complete.I make this declaration based on all information of which I have knowledge, Paid Paid Dole Check Paid preparees PTIN preparet's if self- - Preparer signature ® employed ❑ Must Firm's FEIN Sign Firm's name(or yours If self-employed) 0111. and address ZIP code For Privacy.Notice,get FTB 1131 ENGISP. FTB 8453-EO 2019 Monta Vista High School Speech Boosters Inc. (NEW) Eligibility Checklist (staff use only) Elagibility YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/project/event Identify how the funds will be used to benefit the Cupertino X community Be awarded only once per project X Fors specific needs,not on oin operational p g g, p rational costs X F. Have more than 75%of the requested funds allocated for direct X 26%or more of the requested funds were allocated toward expenses not directly service costs versus administrative costs tied to the proposed program/event/project(i.e.:organizational staffing costs) Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only submit one application NA Proceeds generated from the funded activity may only be used for the conducted activity NA admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved NA by Parks and Recreation Commission City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Community Funding Grant in the past? O Yes O No If, Yes,when? SECTION 1: CONTACT- INFORMATION Legal Name of Cupertino Library Foundation Organization: Web Address: https:llcupertinolibraryfoundation.org Mailing Address: 10800 Torre Ave, City: Cupertino Zip: 95014 Phone: PresidentlExecutive Kiran Varshneya Title. President Director: Email: kvarshneyacupertinolidraryf Telephone Number,. Contact Person: Seetha Lakshmi Title, Board Member Email Address: slakshmi cu ertinolibrar foundation.ar Tele hone p P y gNumber: 3EC i 10N 2. N,0N,-P,,-, 7 1 i`,;tibi!•10 501(c)(3)? * Yes 0 No Year Established 1994 Federa[Tax ID Fiscal Sponsor Name: Fiscal Sponsor Address. City: Zip: Rhone: ECTION 3: ORGAWZ.ATION INFORMATION Total Organization Budget; $50.000 Total#of Board Members: 13 Total #of staff; 0 Total#of Volunteers: 25 Mission Statement: Mission of Cupertino Library Foundation is to provide financial and creative support for multi-generational, rnulti- lingual educational and cultural programs in collaboration with the Cupertino Library. Our vision is a Cupertino Library prepared to provide the most advanced resources, programs, and events to meet the current and future educational and cultural needs of our residents. Brief Description of Organization: Founded in 1994. the Cupertino Library Foundation (Ci_F) is run by a volunteer board and plays dual roles in our community. First, we serve as advocates for the Cupertino Library, We speak out for the Library's interests as a knowledgeable voice from the Cupertino Community. Most recently, we led the initiative to expand the Library with a Program Room extension, construction of which is now in progress. Previously we advocated for the"new" Library(today's building)and got funding for creation of the Teem Room. The second role that CLF plays is to advocate for the Cupertino Community to the Library. In this role,we often find topics of interest or concern in our Community and push to create programming and services to meet those needs. We serve as the catalyst and create pilot programs to test the viability and need in the Community, Brief Description of Services Provided: CLF has solely or in partnership (e.g. with the Library, Chamber of Commerce) organized several Educational, Cultural, and HealthlWellness programs, and Film screenings benefitting the community. Programs offered during the pandemic in 2020 include: 1)Summer Science Contest for middle school students, 2)Education Series aimed at helping students and parents to better look at future careers and their upcoming college decisions_ 3)Writing Workshops for students and adults 4)Laughter Yoga sessions (targeted for seniors and caregivers, but was open to and well attended by the whole community) 5)Webinars on Cybersecurity for seniors (targeted for seniors, but was open to and well attended by the whole community) SECTION 4: GRANT REQUESTS 1.Program/ProjecUEvent Name: Cupertino Library Foundation (CLF)Empower and Connect Seniors Program 2.Details)and/or duration of program/project/event(if applicable):12 months starting mid 2021 3.Total program/projecUevent budgeC$25,000 4.Requested Amount: $15,000 Percent of total program/inroject/event budget: 60% 5.ProgrardProject projected income: $0 Percentage of your organization's projected income:0% 6.Type of Request: []Capital Improvement 12 Program Support 0Event ❑One-gme project 12 Other: Market and promote the program through City 7.This grant will fund a(n): ❑ Existing program/project/event established in (year) 0 New program/project/event S.Describe the purpose of requested funds and the services that will be provided: The Age Friendly Cupertino Task Force has identified ostler adults are the fastest growing age group in the community. However, there are many gaps in information, education,and entertainment for our Seniors; there is no senior strategy nor well-defined effort to address topics of specific interest to our fastest growing demographic With the pandemic raging,we realize that now more than ever,we need to offer programs to close the generational digital gap.To this end, CLF proposes to pilot a program called Empower and Connect Seniors.This program consists of live and interactive virtual enrichment classes to learn technology, health and wellness topics, and many other helpful resources. In addition to learning sessions,we envision sessions that would offer a safe virtual meeting place for seniors to just hangout and engage with their peers. Please see attached file CLF-2021-Gant-ApplicationSupport-for-Pmmpt08.mp4 for more information 9.Please provide a line item breakdown of how the funds will be used in the categories below. If a category is not a licable, ut$0: Admin Staff A$3�00 b Materials/E ui ment c Entertainment RoomNenue Rental Other Professional Services Project Mana errantOther Course Provider ota1 10.Explain how the request aligns to City mission and values: The mission of the City of Cupertino is stated on the website as follows:to provide exceptional service,encourage all members of the community to take responsibility for one another,and support the values of education, innovation,and collaboration. The proposed Empower and Connect Seniors program by CLE while expressly designed to support the seniors will also benefit any member of the community looking for digital literacy and social connection. It offers numerous education classes on topics ranging from communication platforms like Zoom, Gmail, Facebook, etc.to how to use popular food/grocery/prescriptions,and a whole host of other fun and helpful categories. The innovative program creates a sense of community, promotes continuous learning,teaches new skills for those wanting to achieve specific goals, increases socialization and reduces isolation and loneliness. Based on these attributes of our program.we believe,our grant request aligns very well with City's miss 11.Describe how the program/proJectlevent fills a community need.Who identified this need?What other similar projecNprogram/event exists to serve Cupertino residents? How is your proposed project/program/event unique from similar projechyprograms/events or how do you collaborate to avoid duplication? According to the 2019 report from Age Friendly Cupertino Task Force, percent of residents who are 65 and older will increase from 12% to 17.5% by 2025, which amounts to approximately 10,000 residents. Given the growing cost and shortage of independent and assisted living,we anticipate many seniors would choose to"age in place". The U.S. Centers for Disease Control and Prevention defines aging in place as'the ability to live in one's own home and community safely, independently,and comfortably, regardless 0f age, income, or ability level'. Transformative technological solutions for senior care are constantly being innovated. However, there are many seniors among us who find even the current technological solutions complex and daunting. Getting our seniors comfortable with technology will go a long way In helping them with their ageing In place goals. Please see attached file CLF-2021-Grant-ApplicationSupport-for-Promptll.pdf for more Information 12. Who will be served by this grant? - Cupertino Senior community, care givers, and Cupertino Adult community who are interested in getting educated and informed of topics relevant to seniors. While Cupertino has around 7000 residents who are 65 and older,for the initial roll out of our program,we hope to reach 100 residents. a)Number of individuals total: 100 b)Number of Cupertino residents: 100 c)Particular community groups: 55 and older adults; residents of retirement community; members of Cupertino Senior Center; older adult members of CLF mailing list. , . d)Will the program/projecUevent be available to the entire community/public or are there any eligibility criteria? Program and events will be made available to the entire community/public. Where possible recordings of events will also be made available for viewing after the events. e)Will there be a charge or fee for the program/project/event(if applicable) No 0 What outreach methods does your organization use to promote the programlprojecUevent('d applicable)? CLF Web site,CLF member mailing list, Cupertino Senior Center mailing list, postings in Social Media and multiple community NextDoor groups. 13. Describe haw the funds will be used to benefit or impact the Cupertino community: The funds will be used to offset the cost of providing the on-line classes and interactive sessions offered by our Empower and Connect Seniors program. This program will help bridge the digital divide and the digital generational gap experienced by the older adults; it will provide skills necessary to a) use devices such as PCs,Tablets, and Smart Phones to navigate online safely, b) stay connected to each other and to the goods, services, and supports needed to stay healthy and thrive.Through technology, they can check in with family and friends,share their knowledge and volunteer their time with the communities,stay in touch with their health care providers,find healthy foods, perform meaningful work, and learn new skills—all from a safe distance. 14, Demonstrate that the member implementing and managing the program/projecUevent have adequate experience: 1. Cupertino Library Foundation is run by a volunteer board of 13 directors who are all highly qualified and accomplished professionals from Silicon Valley.They all have a track record of implementing several successful community programs. Please visit our website cupedinolibmryfoundation.org to see all the programs implemented by CLF board of directors. While the contact person for the Empower and Connect Seniors program will be Seetha Lakshmi who organized the successful Cybersecurity webimar series in 2020, the whole board will stay vested in the success of this program. 2)CLF will partner with a content provider, an SF based company. who has developed an extensive catalog of courses, a platform to deliver the courses,and a number of instructors/guides. Several community agencies on aging across the country are currently using this company's technology solution. 15. How will success of the program/pr0ject/event be measured?: Number of participants and Participants Comments for each course/event. 16.WIII more than 75%of the requested funds go towards direct service costs versus administrative costs? 0 Yes 0 No 17.Will you collaborate with other organizations to deliver the program/project/event funded by this grant? If so, which organizations? Yes. Cupertino Senior Center, Cupertino Library, and the Content Provider mentioned under 14. 18. If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants, please describe this support: City has provided use of the city community hall and recording services for the community programs organized by CLF 19.Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of program/project/event(e.g.fee waivers)? If so, please describe this anticipated support: No 20. If you are a multi-jurisdictional organization, describe any funding requested from other agencies/organizations in regards to this program/project/event request. Indicate whether the funding was granted, denied, or is still pending: NA 21.How would you fund the program/project/event if you do not receive the requested funding?: CLF's Empower and Connect Seniors program is unique and configured to train our local seniors who today do net have access to benefit from the digital programs currently offered by Cupertino library, CLF and other organizations.We believe large number of senior community is left out from the broad offerings of educational materials, on-line services, and social networking that other demographics enjoy. Due to the projected high cost, It would be hard for CLF to solely fund this program for a whole year,for a large number of participants.Without the funding from the City requested in this proposal, CLF would fund a pilot program for a 2 month period for a limited number of participants. [SECTION 5: PRIOR FUNDING 1. If you received a Community Funding Grant in prior years,indicate the amounts for each year and describe how those funds were used: N/A No Community Funding Grant was received in prior years 2. If you received a Community Funding Gram last year: a. Please provide a line item breakdown of how the Community Funding Grant was used last year in the categories below. If a category is not applicable, put$0: .Admin Staff I.Materials/Equipment it.Entertainment v. RoomNenue Rental .Other Professional Services .Other Total $ L. Who was served by the grant last yei i. Number of individuals total: ii.Number of Cupertino residents: iii. Particular community groups iv.Was the program/project/event available to the entire community/public or are there any eligibility criteria? v.Was there a charge or fee for the program/projec0event(if applicable)? vi.What outreach methods did your organization use to promote the program/project/event (if applicable)? c.Was the program/project/event successful?Please indicate how success was measured: 3. Please indicate any additional funding received last year from other sources and provide your financial statement if available: Attachments:Attach your financial statment,and any other helpful information about your project. CLF-2021-Grant-Applicaton-Support-far-PromptD8.mp_ CLF-2021-Grant-Application-Support-for-Promptl l.pdf Program Manager Signature Board Member,Cupertino Library Foundation. Date Signed 01/31/2021 Prompt 11. Describe how the programlprojeclievent fills a community need.Who identified this need? What other similar project/program/event exists to serve Cupertino residents?How Is your proposed projectlprogramlevent unique from similar projects/programs/events or how do you collaborate to avoid duplication? 1. According to the 2019 report from Age Friendly Cupertino Task Force, percent of residents who are 65 and older will increase from 12%to 17.5% by 2025.which amounts to approximately 10,000 residents. Given the growing cost and shortage of independent and assisted living,we anticipate many seniors would choose to"age in place". The U.S. Centers for Disease Control and Prevention defines aging in place as the ability to live in one's own home and community safely,independently,and comfortably,regardless of age,income,or ability level'. Trensformative technological solutions for senior care are constantly being innovated. However,there are many seniors among us who find even the current technological solutions complex and daunting. Getting our seniors comfortable with technology will go a long way in helping them with their ageing in place goals. 2. Cupertino Parks & Recreation department used to offer a variety of programs to enrich our older adults. However, many classes have been postponed or suspended due to COVID-19; only a handful of classes are being offered in a virtual set up.CLF's Empower and Connect Seniors program is designed to offer numerous on-line Gasses on a variety of topics.Santa Clara Library may offer a few on-line Gasses. 3. Uniqueness of CLF's Empower and Connect Seniors program: a. Totally free to Cupertino residents. b. Residents will have an 'ali-youran-eaC buffet style offering of courses. c. With the possibility of round the clock scheduling, residents will have more options to choose the time that works best for them. d. The underlying technology platform of our program allows new classes to be made available without much effort. e. Residents have the opportunity to develop and/or teach courses 4. CLF works closely with the Cupertino Library.We promote and sponsor library's programs and events. CLF also a collaborative relationship with the Cupertino Senior Center. Cupertino Library Foundation (NEW) Eligibility Checklist (staff use only) Eligibility YES ' NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/project/event Identify how the funds will be used to benefit the Cupertino X Community Be awarded only once per project X For specific needs,not on going,operational costs X Have more than 75%of the requested funds allocated for direct service costs versus administrative costs X Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only submit one application NA Proceeds generated from the funded activity may only be used for the conducted activity NA admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved NA by Parks and Recreation Commission City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Community Funding Grant in the past? 0 Yes No If, Yes,when? 17?.-_ -L. - Legal Name of APALI Organization: Web Address: APALLORG Mailing Address: City: CuperUnu Zip: 95014 Phone:- PresidentlExecutive Michael Chang Title: Executive Director Director: Email: michaelcliang@apali.org TOuphonc Numbcr:michaelchang@apali-org Contact Person: Michael Chang Title: Executive Director Email Address: michaelcliang@apali.org Telephone Number :=DTION 2: MON-PROFIT iAlFDF'.;' 501(c)(3)? * Yes O No Year Established 2017 Federal Tax ID: Fiscal Sponsor Name: Asian Pacific American Leadership Institute (APALI) Fiscal Sponsor Address: City: Cupertino Zip: 95014 Phone:- T€;` ORGANIZATION iNFORMATtO�I Total Organization Budget: $190,000 Total # of Board Members: 3 Total A of staff: 3 Total # of Volunteers: Mission Statement: THE MISSION of the Asian Pacific American Leadership Institute is to elevate the standing our community-- through civic training and leadership networking--by developing effective access, proper representation, meaningful presence, and influential participation in American political and civic life. Brief Description of Organization: THE APAL[ LEADERSHIP MODEL is nationally-recognized for being a transformative experience in personal leadership growth and expanding social vision--with an emphasis on character development, community building, networking, and being part of a civic pipeline for Asian Americans and other underrepresented groups.The APALI Model features an integrated approach which is wholistic, culturally-informed, cross-generational and community- based, Brief Description of Services Provided: The APALI Youth Leadership Academy is a summer program, led by a team of six peer mentors who are paid interns, presents impactful workshops to engage students in exploring Asian American identity, community, and civic engagement. Program features include: " WORKSHOPS & ACTIVITIES that engage students to share stories related to identity, develop community awareness, and practice leadership skills. PEER MENTORS to provide academia and personal support to help students get the most out of their experience. ALUMNI INVOLVEMENT to be inspiring role models who can share valuable career and college experiences. INCLUSIVE COMMUNITY which is supportive and safe--transcending ethnic, socioeconomic class, gender, sexuality. and religious boundaries. The Youth Leadership Academy is presented by APALI in collaboration with De Anza College's Asian American Studies Department and students enroll in ASAM 10 during summer. SECTION 4: GRANT REQUESTS 1.Program/Project(Event Name: APALI Youth Leadership Academy 2.Debuts)and/or duration of program/projectlevent(if applicable):June 28-August 4, 2021 3.Total programlprojeoPevent budget: $24,618 4.Requested Amount: $20,000 Percent of total program/project/event budget: 81% 5.PrograMProject projected income: $0 Percentage of your organization's projected income: 6.Type of Request: ❑Capital Improvement 0 Program Support ❑Event ❑One-time project Cl Other: 7.This grant will fund a(n): 0 Existing progranJproject/event;established in 2017(year) ❑ New program/project(event 8. Describe the purpose of requested funds and the services that will be provided: APALI's Youth Leadership Academy is a six-week program for high school and college students to loam about the Asian American community and embark on a personal journey to explore identity, history,education, career paths, leadership and civic engagement. The requested funds totaling$20,000 will be used for: Six college student Peer Mentor internship stipends$1,800 x 6=$10,800 Peer Mentor Intern Trainer=$8.318 Supplies and miscellaneous expense= $882 9. Please provide a line item breakdown of how the funds will be used in the categories below. If a category is not applicable, ut$0: Admin Staff $ Materials/E ui ment $88 Entertainment $ Rdxan ue Rental $ Other Professional Services Peer Mentor Intern Trainer $8,31 Other Six Peer Mentor Stipends $10,80 otal $831 811,68 10. Explain how the request aligns to City mission and values: APALI's Youth Leadership Academy aligns well and supports the City of Cupertino's mission 'to provide exceptional service,encourage all members of the community to take responsibility for one another, and support the values of education, innovation and collaboration.'APALI's Youth Leadership Academy encourages students to take pride and understand their community. In particular, the youth leadership program encourages students to explore the privilege and responsibility of citizenship and to incorporate civic engagement into their life journey. 11.Describe how the program/projeclievent fills a community need.Who identified this need?What other similar project/program/event exists to serve Cupertino residents? How is your proposed project/program/event unique from similar projects/pmgmms/events or how do you collaborate to avoid duplication? APALI's Youth Leadership Academy addresses the need for students, especially those from families which are first and second generation immigrants, to understand their history, heritage, and identity as American cultural groups. In addition, the program brings back dozens of civically engaged alumni with careers in government, nonprofit, education,and corporate sectors.The program inspires students to develop personal mourners that address personal, academic, career,and civic engagement interests. Through a team of six college peer mentors,the program build a strong community bond that is sustained after graduation by an alumni program. 12.Who will be served by this grant? High school and college stutlents. a)Number of individuals total: 40 b)Number of Cupertino residents: 20 c)Particular community groups: Asian American students--including Chinese, Indiand3outh Asian, Vietnamese/SE Asian, Filipino, Korean, Japanese. multiple ancestry Asian Americans,etc, White, Lenox, and other students. d)Will the programlproject/evenl be available to the entire community/public or are there any eligibility criteria? The program will be available to the entire community. e)Will there be a charge or fee for the prograrNproject/evenl(if applicable) APALI does not charge any fee for the Youth Leadership Academy. In collaboration with the Asian American Studies Department at De Anza College,APALI presents the program with a team of six college-student peer mentors with paid internships.Yount Leadership Academy participants who are students are enrolled at De Anza and earn college credit for completing the APALI program. f)What outreach methods does your organization use to promote the program/project/event(if applicable)? APALI conducts an extensive three-month outreach and recruitment period prior to the beginning of the program. In particular, APALI works with FUHSD on outreach at district, school,and class levels. Alumni and community leaders also assist greatly in the outreach effort. 13. Describe how the funds will be used to benefit or impact the Cupertino community: APALI's Youth Leadership Academy has Inspired many youths to become civically engaged as professionals or as citizen volunteers. Cupertino examples include Assemblymember Evan Low who was an early YLA alum from 2002 and Ms. Neesha Tambe is a YLA alum from 201D who currently serves on the Park and Recreation Commission. Many YLA alums apply and return as college mentor interns. There are literally hundreds of other APALI alumni from varlous programs that are civically engaged in the region, including those on Cupertino/other city councils and school boards, as well as those working in local government and nonprofit organizations. 14.Demonstrate that the member implementing and managing the program/projecf/event have adequate experience: The six college-level student peer mentors will be selected based on a competitive process for paid Internships. Many peer mentors were graduates of the Youth Leadership Academy and had been recommended by their own pear mentors. Peer mentors are college students who have taken courses in Asian American/ethnic studies and a demonstrated track record of student organizing and leadership. Anthony Le will be serving as a well-qualified and experienced Peer Mentor trainer. He was a YLA alum from 2009 and holds a Masters in Leadership Studies from the University of San Diego. He has been involved in youth leadership training for many years. 15.How will success of the program/praject/event be measured?: It is expected that over 90 percent of the participants will be able to complete the six-week program and complete all required personal and group teaming experiences. In 2020, 80%of 44 participants rated their overall experience as'very impactful'or'extremely impactful'.APALI aims to achieve similar participant participant Impact with Its 2021 program, 16.Will more than 75% of the requested funds go towards direct service casts versus administrative costa? O Yes O No 17.Will you collaborate with other organizations to deliver the progran/project/event funded by this grant? If so, which organizations? De Anza College and FUHSD 18, If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants, please describe this support: N/A 19.Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of program/project/event(e.g.fee waivers)? If so, please describe this anticipated support: For many years,the City of Cupertino's City Manager and Department Directors hosted APALI students for a day to learn about their careers and work, In 2020, during the pandemic,APALI implemented a (surprisingly)successful online program because of the emphasis on student engagement with the assistance of six peer mentors leading small groups. The 2021 program will again be an online experience for participants. 20.If you are a multi-jurisdictional organization,describe any funding requested from other agencies/organizations in regards to this program/projectlevent request. Indicate whether the funding was granted,denied, or is still pending: N/A 21.How would you fund the programlprojec7event if you do not receive the requested funding?: APALI has struggled to continue its leadership programs,as corporate sponsorships has decrease dramatically in 2020 during the pandemic.APALI may forced to reduce its leadership programs depending on amount of funding for 2021. SECTION ,. PRIOR FUNDING 1. If you received a Community Funding Grant in prior years,Indicate the amounts for each year and describe how those funds were used: N/A 2. If you received a Community Funding Grant last year: a. Please provide a line item breakdown of how the Community Funding Grant was used last year in the categories below. If a category is not applicable, put$0: i.Admin Staff ii. Materials/Equipment iii. Entertainment v.Room/Venue Rental .Other Professional Services .Other Total $ I.Who was served by the grant last year? NIA 1.Number of individuals total: ii. Number of Cupertino residents: iil.Particular community groups iv.Was the program/project/event available to the entire community/public or are there any eligibility criferi0 v.Was there a charge or fee for the program/project/event(if applicable)? vi.What outreach methods did your organization use to promote the program/projectlevent(if applicable)? c.Was the program/projecl/event successful?Please indicate how success was measured: 3.Please indicate any additional funding received last year from other sources and provide your financial statement if available: Attachments:Attach your financial statment, and any other helpful information about your project. APALI IRS Letter Tax-Exemption.pdf Articles of Incorporation of APALI - Fileo.pdf APALI 2019 tax-exempt tax returns.pfff 2020 Revenue Expp,Dsga,W 2021 SOS SI f Info Certified Eftg,pd Program Manager Signature Executive Director Date Signed 01/28/2021 INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. 0. SOX 2508 CINCINNATI, OH 45201 Employer Identification Number: Date: MAR 10O1T � DLN: ASIAN PACIFIC AMERICAN LEADERSHIP Contact Person: INSTITUTE CUSTOMER SERVICE ID# Contact Telephone Number: CUPERTINO, CA 95014-0000 (877) 829-5500 . Accounting Period Ending: December 31 Public Charity Status: 509(a) (2) Form 990/990-�EZ/990-N Required: Yes Effective Date of Exemption: February 27, 2017 Contribution Deductibility: Yes Addendum Applies: No I i Dear .Applicant: We're pleased to tell you we determined you're exempt from federal income tax under Internal Revenue Code (IRC) Section 501(c) (3) . Donors can deduct contributions they make to you under IRC Section 170. You're also qualified to receive tax deductible bequests, devises, transfers or gifts under Section 2055, 2106, or 2522. This letter could help resolve questions on your j exempt status. Please keep it for your records. Organizations exempt under IRC Section 501(c) (3) are further classified as either public charities or private foundations. .We determined you're a public charity under the IRC Section listed at the top of this letter. If we indicated at the top of this .letter that you're required.to_file:Form . 990/990-EZ/990-N, our records show you're required to file an annual ' information return (Form 990 or Form 990-EZ) or electronic notice (Form 990-N, the e-Postcard) . If you don't file a required return or notice for three consecutive years, your exempt status will be automatically revoked. If we indicated at the top of this letter that an addendum applies, the enclosed addendum is an integral part of this letter. For important information about your responsibilities as a tax-exempt organization, go to www.irs.gov/charities. Enter 114221-PC" in the search bar to view Publication 4221-PC, Compliance Guide for 501(c) (3) Public Charities, which describes your -recordkeeping, reporting, and disclosure requirements. Letter 947 3989685 FILED of Se stme Of calftria Articles of Incorporation FEB A 1 2 of Asian Pacific American Leadership Institute a California Nonprofit Public Benefit Corporation Article I The name of this corporation Is Asian Pacific American Leadership Institute. Article II This corporation is a Nonprofit Public Benefit Corporation and is not organized for the private gain of any person. It is organized under the Nonprofit Public Benefit Corporation Law for charitable i purposes. [ Article III The name and address in the State of California of this corporation's initial agent for service of process is Michael Chang,�A Cupertino, CA 95014. Article IV The Initial street and mailing address of this corporation Is Cupertino,CA 95014. Article V This corporation shall have no members. Article VI A. This Corporation is organized and operated exclusively for exempt purposes within the meaning of Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the "Code") B. No substantial part of the activities. of this corporation shall consist of carrying on propaganda,or otherwise attempting to influence legislation,and this corporation shall not participate in or Intervene in any political campaign(including the publishing or distribution of statements)on behalf of,or in opposition to, any candidate for public office, C. Notwithstanding any other provision of these articles of incorporation,this corporation shall f not carry on any activities not permitted to be carried on (I)by a corporation exempt from federal income tax under Section 501(c.)(3) of the Code or (ii) by a corporation, contributions to which are deductible under Section 170(c)(2)of the Code. i Article VII j A. The property of this corporation is irrevocably dedicated to charitable purposes and no ] part of the net income or assets of this corporation shall ever inure to the benefit of any j director, officer or member thereof or to the benefit of any private person, except that this f corporation is authorized and empowered to pay reasonable compensation for services I rendered and to make payments and distributions in furtherance of the purposes set forth in Article II hereof. B. Upon the dissolution or winding up of the corporation,its assets remaining after payment, or provision for payment, of all debts and liabilities of this corporation shall be distributed to a nonprofit fund, foundation or corpor• i which is organized and operated exclusively for charitable purposes and which ha est lisped its tax exempt st us under Internal Revenue Code section 501(c)(3), l Micylaell ihang, IncorpoE'at(lr I { i { 1 ' 1 1 I K-reuy c:-tify that I ,4 foregoing transc ipt of _pago(s) is a full,tF.Ua and corract copy of tho original record in the Custody of Oia Gafifornia Sm-rotary of State's officm. ?,rix1?AEDIlAA.;ixiwol;iri)W;,Yat+s I FORNEY ACCOUNTANCY 1973 FAYE CT PLEASANT HILL, CA 94523 925-323-2892 March 6, 2020 Asian Pacific American Leadershi Institute Cupertino, CA 95014 Dear Client: Your 2019 Federal Return of Organization Exempt from Income Tax will be -electronically filed with the Internal Revenue Service upon receipt of a signed Form 8879-EO - IRS e--file Signature Authorization. No tax is payable with the filing of this return. Your 2019 California Exempt Organization Annual Information Return will be electronically filed with the State of California upon receipt of a ! signed Form 8453-EO. There is a balance due of $10 payable by May 15, 2020. Mail your California payment voucher, Form 3586, on or before May j i 15, 2020 to: ! FRANCHISE TAX BOARD P.O. BOX 942857 SACRAMENTO, CA 94257-0531 Enclosed is your California Registration/Renewal .Fee Report to the Attorney General. The original should be signed at the bottom of page one. There is a fee due of $75 payable by May 15, 2020. Make the check or money order payable to "Attorney General's Registry of Charitable Trusts" and mail .your California report on or before May 15, 2020 to: REGISTRY OF CHARITABLE TRUSTS P.O. BOX 903447 SACRAMENTO, CA 94203-4470 Please be sure to call us if you have any questions. Sincerely, Bryce Forney Voucher at bottom of page. DO NOT MAIL A PAPER COPY OF THE CORPORATE OR EXEMPT ORGANIZATION TAX RETURN WITH THE PAYMENT VOUCHER. If the amount of payment is zero,do not mall this voucher. WHERE TO FILE: Using black or blue ink, make check br money order payable to the "Franchise Tax Board."Write the corporation number, FEIN, CA SOS file number.and "2019 FTB 3586"on the check or money order. Detach voucher below, Enclose, but do not staple, payment with voucher and mail to: FRANCHISE TAX BOARD PO BOX 942857 SACRAMENTO CA 94257-0531 Make all checks or money orders payable in U.S.dollars and drawn against a U.S.financial institution. WHEN TO FILE: Corporations--File and Pay by the 15th day of the 4th month following the close of the taxable year. S corporations—File and Pay by the 15th day of the 3rd month following the. close of the taxable year. Exempt organizations—File and Pay by the 15th day of the 5th month following the close of the taxable year. When the due date falls on a weekend or holiday,the deadline to file and pay without penalty is extended to the next business day. 1 ONLINE SERVICES: Corporations can make payments online using Web Pay for Businesses. Corporations can make an immediate payment or schedule payments up to a year in advance. Go to ftb.ca.govlpay for more Information. DETACH HERE__—________ IF NO PAYMENT 15 DUE, DO NOT MAIL THIS VOUCHER ___——______ DFTACH HERE_ CAUTION:You may be required to pay electronically,see instructions. TAXABLE YEAR Payment Voucher for Corporations CALIFORNIA FORM 2019 and Exempt Organizations a-filed Returns 3586 (e-file) ASIA 000000000000 19 FORM 3 TYH 01�-01--19 TYE 12-31-19 ASIAN PACIFIC AMERICAN LEADERSHIP INSTITUTE MICHAEL CHANG CUPERTINO CA 95014 AMOUNT OF PAYMENT 10. 1 CACA1201L 11115/19 FT6 3586 2019 1N ANNUAL MAILRegistry .of Charitable Trusts Reggistry REGISTRATION RENEWAL FEE REPORT P.O.Box903447 TO ATTORNEY GENERAL OF CALIFORNIA raeray and justice Sacramento,CA 94203-4470 Section 12586 and 12587,California Government Code under law (916)210-6400 11 Cal.Code Regs.section 301-307,311,and 312 WEB SITE ADDRESS: Failure to submit this report annually no laterlhan the 15th day of the 5th month atter the end ot1he organization's accounting period may result in the loss of tax exemption and the assessment of a minimum tax of$8D0,plus Interest,andlorfrnes or filing penalties as defined In Government Code section 125116.1. IRS extensions will be honored, Check if: State Charity Registration Number ❑Change of address ASIAN PACIFIC AMERICAN LEADERSHIP INSTITUTE ❑Amended report Name of Organization Corporate or Organization No. Aaaress(Number and street) CUPERTINO, CA 95014 Federal Employer I.D.No. City or Town,State and ZIP Code ANNUAL REGISTRATION RENEWAL FEE SCHEDULE(11 Cal,Code Regs,sections 301-307,311,and 312) Make Check Payable to Attorney General's Registry of Charitable Trusts Gross Annual Revenue Eft Gross Annual Revenue F Gross Annual Revenue Fee 3 Less than$25,000 0 Between$100,001 and$250,000 $50 Between$1,000,001 and$10 million $150 Between$25,000 and$100,000 $25 Between.$250,001 and$1 million $75 Between$10,000,001 and$50 million .$225 Greater than$50 million $300 PART A- ACTIVITIES For.your most recent full accounting.period(beginning 1/01/19 ending 12/31/19 )list: Gross annual revenue $ 351,673. Total assets $ 493,948. PART B -- STATEMENTS REGARDING ORGANIZATION DURING THE PERIOD OF THIS REPORT Note: If you answer'yes"to any of the questions below,you must attach a separate page providing an explanation and.details for each "yes"response.Please review RRF-1 instructions for information required. Yes No 1 During this reporting period,were there any contracts, loans, leases or other financial transactions between the organization and any officer,director or trustee thereof either directly or with an entity in which any such officer, ❑ ❑ director or trustee had any financial interest? X 2 During this reporting period,were there any theft, embezzlement,diversion or misuse of the organization's charitable ❑ property or funds? 3 During this reporting period, did non program expenditures exceed 50% of gross revenue? 0 0 i 4 During this reporting period,were any organization funds used to pay any penalty,fine or judgment? If you filed a ❑ Form 4720 with the Internal Revenue Service, attach a copy. 5 During this reporting period,were the services of a commercial fundraiser or fundraising counsel for charitable purposes used? If"yes," provide an attachment listing the name,address,and telephone number of the ❑ service provider. 6 During this reporting period,did the organization receive any governmental funding? If so, provide an attachment listing ❑ the name of the agency, mailing address, contact person, and telephone.number. 7 During this reporting period,did the organization hold a raffle for charitable purposes? If"yes,"provide an attachment ❑ indicating the number of raffles and the date(s)they occurred. 8 Does the organization conduct a vehicle donation program? If"yes,"provide an attachment indicating whether ❑ ❑ the program is operated by the charity or whether the organization contracts with a commercial fundraiser for x charitable purposes. 9 Did your organization have prepared an audited financial statement in accordance with generally accepted accounting ❑ principles for this reporting period? Organization's area code and telephone number Organization's o-mail address MICHAELCHANG@APALI.ORG I declare under penalty of perjury that I have examined this report,including accompanying documents,and to the best of my knowledge and belief,the content is true,correct and complete. MICHAEL CHANG EXECUTIVE DIRECTOR Signature of authorized officer Printed Name Title Date CAEA9801L 11/20/18 RRF-1 (08 2017) Form 990 OMB No.1545-OG47 (Rev.January2020) Return of Organization Exempt From Income Tax 2019 Under section 501(c),527,or 4947(a)(1)of the Internal Revenue Code(except private foundations) Department of the Treasury ■ Do not enter social security numbers on this form as it may be made public. Open to.Publfc Internal Revenue Service a Go to www.irs.govIForm990 for instructions and the latest information. Inspection A For the 2019 calendar year,or tax year beginning ,2019,and ending , B Check if applicable: C D Employer Identlftcation number Address change Asian Pacific American Name change Leadership Institute E Telephone number Initial return — iiP Final return/terminated Cupertino, CA 95014 Amended return to Gross receipts $ 351,673. Application pending F Name and address of principal officer: Micheal Chang H(a)Is this a group return for subordinates?H Yes X No Same As C Above H(b)Are all subordinates included? Yes No If"No,"attach a list.(see instructions) Tax-exempt status: X 501(c)(3) 501(c) ( (inse(t no.) I 14947(a)(I)or 527 J Website: ► www.a all.Or H(c)Group exemption number' K Form of organization: X Corporation I Trust I I Association Others L Year of formation: 2017 M State of legal domicile: CA Part I , SLIMmary 1 Briefly describe the organization's mission or most significant activities:To train_ socially con cious and effective civic leaders &—develop�leadership i elines in overnmen non rcfit, --- -----------------------------P ------ --------p------- c education sectors. ----------------------------------------------- —d--.-t-- ---------- 2 Check this box ► If the organization discontinued its operations or disposed of more than 25%of its net assets. — 3 Number of voting members of the governing body (Part VI, line 1 a)................................... 3 3 4 Number of independent voting members of the governing body (Part VI, line 1 b)............:.......... 2 4 °1 5 Total number of individuals employed in calendar year 2019 Part V, line 2a 6 Total number of volunteers (estimate if necessary).. ............................ 0 7a Total unrelated business revenue from Part Vlll, column (C), line 12................................. 7a 0. b Net unrelated business taxable income from Form 990-T, line 39.................................... 7b 0. Prior Year Current Year 8 Contributions and grants (Part VIII, line 1h)....................I..................... 276,532. 346,145. c 9 Program service revenue (Part Vlll, line 2g)........................................ 4,734. 5,349. 10 Investment income Part VIII,column (A), 3,4, and 7d .......................... ( ( ) } 50. 179. 11 Other revenue (Part VIII, column (A), lines 5, 6d,8c, 9c, 1Oc, and I Ie)................ 12 Total revenue— add lines 8 through 11 (must equal Part VIII, column (A), line 12)..... 281,316. 351, 673. 13 Grants and similar amounts paid (Part IX, column (A), lines 1-3)...................... 577. 14 Benefits paid to or for members (Part IX, column(A), line 4)......................... 15 Salaries, other compensation, employee benefits (Part IX,column (A), lines 5-10).... 66,678. 126, 905. e 16a Professional fundraising fees (Part IX, column(A), line 11 e).......................... b Total fundralsing expenses (Part IX, column (D), line 25) ► 12,117. P ( ( } ) ............. 45, 960. 54,4 17 Other expenses Part IX, column A , lines l 1a-11d, 11f-24e ............ 63. 19 Total expenses. Add lines 13-17(must equal Part IX, column (A), line 25)............. 113,215. 181,368. 19 Revenue less expenses. Subtract line 18 from line 12................................ 168,101. 170,305. Beginning of Current Year End of Year 9 20 Total assets (Part X, line 16)...................................................... 321,522. 493, 948. 21 Total liabilities(Part X, line 26)................................................... 1,657. 3,778. i 5 22 Net assets or fund balances. Subtract line 21 from line 20............................ 319,8657: 490,170. 1.PArt:11,-,','.,.1Signature Block Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,it is true,correct,and complete.Declaration of preparer(other than officer)is based on all information of which preparer has any knowledge. Sign , Signature of officer Date Here ' Michael Chang Executive Director Type or print name and title PrmVType preparer's name Preparer's signature Date Check X if PTIN Paid IM self-employed Preparer Firm's name USe Only Firm's address Firm's EIN Phone no, May the IRS discuss this return with the preparer shown above? (see instructions)...................................... 1X1 Yes IlLo BAA For Paperwork Reduction Act Notice,see the separate instructions. TEEAo101I- MOM Form 990 (2019) Form 990 (2019) Asian Pacific American Page 2 PartIll Statement of Program Service Accomplishments Check if Schedule O contains a response or note to any line in this Part III................................................. 1 Briefly describe the organization's mission: -Deliver tr_a_inincl via Civic_ Lea_d_e_rship, Youth—Leadership and College Internship______ programs__— Including—alumni—and Senior Fellos program we have served—over members of the community__----_---__ _________________________________ 2 Did the organization undertake any significant program services during the year which were not listed on the prior Form990 or 990-EZZ........................................................................................ ❑ Yes 0 No If"Yes,"describe these new services on Schedule O. 3 Did the organization cease conducting,or make significant changes in how it conducts, any program services?.... Yes FX No If"Yes,"describe these changes on Schedule 0, 4 Describe the organization's program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c}(4)organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any,for each program service reported. 4a(Code: ) (Expenses $ 132,006. including grants of $ ) (Revenue $ ) Pr_o_v_id_e_d e_d_uca_ti_on_ services---- vi_a__our__Civic_L_e_adership P_x_ogram a_n_d_Y_outh__Lea_d_ers_h_ip____ Programs._.Program was _delivered in partnership with D_e_A_nz_a__Co_m_m_un_iy C_olle_ge a_n_d Joint funded with the FoothillDeAnza Foundation. ---------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ------------------------------------------------------------------ ----------------------------------------------------------------- ------------------------------------------------------------------ ----------------------------------------------------------------- 4b(Cade: ) (Expenses $ including grants of $ ) (Revenue $ ) ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------_....._................._...._.._........--.........M......._---------- ----------------------------------------------------------------- ---.-.-.---,..-.- -.-.-..-.,-- --.----------.....- -..-..-. - -- ------- i - -..-..-.......-.............................................^-..--.---.--..--...........-...........-.......--------------------------------- i .-........J-- .------------ -...........-..- - ----------------------------------------- ----------------------------------------------------------------- -------------------------------------------------------------- - i ------------------------------------------------------------------ 1 . ---------------------------------------.--------------- --.------ � 4c(Code: ) (Expenses $ including grants of $ )(Revenue $ ) -------------------------------------------------------------.. --- ----------------------------------------------------------------- I --------------------------------------------------------....._--- ----------------------------------------------------------------- ----------------------------------------------------------------- ------------------------------------------------------------------ ----------------------------------------------------------------- ------------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ---------------------------------------------_. --_._ ---------------- 4 d Other program services (Describe on Schedule O.) (Expenses $ including grants of $ ) (Revenue $ ) 4e Total program service expenses ► 132,006. BA A TEEA0102L 07/31/19 Form 990(2019) Form 990 (2019) Asian Pacific American Page 3 Part ly:- Checklist of Required Schedules 1 Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If'Yes,'complete Yes No ScheduleA...................................................................................................•.•. 1 X 2 Is the organization required to complete Schedule B, Schedule of Contributors(see instructions);?............•........ 2 X 3 Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If'Yes,'complete Schedule C, Part 1.:............................................................ 3 X 4 Section 501(c)(3)organizations.Did the organization engage in lobbying activities,or have a section 501(h)election in effect during the tax year? If'Yes,'complete Schedule C, Part 11.................................................. 4 X 5 Is the organization a section 541(c)(4),501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as define dd 1n Revenue Procedure 98.19? If'Yes,'complete Schedule C, Part III....•. 5 X 6 Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds.or accounts? If'Yes,'complete Schedule D, Part ........................................................................................ .. 6 X .................. 7 Did the organization receive or hold a conservation easement, including easements to preserve open space,the environment, historic land areas, or historic structures? If'Yes,'complete Schedule D, Part 11......................... 7 X 8 Did the organization maintain collections of works of art, historical treasures, or other similar assets? It'Yes,' complete Schedule D, Part III................................................:...................:................. 8 X 9 Did the organization report an amount in Part X, line 21,for escrow or custodial account liability,serve as a custodian for amounts not listed in Part X; or provide credit counseling,debt management,credit repair,or debt negotiation services? If'Yes,'complete Schedule D, Part IV.................................................................... 9 X 10 Did the organization, directly or through a related organization, hold assets in donor-restricted endowments or in quasi endowments? It'Yes,'complete Schedule D, Part V..................................................... 10 X 11 If the organization's answer to any of the following questions is'Yes',then complete Schedule D, Parts VI,VII,Vill, IX,. or X as applicable. a Did the organization report an amount for land,buildings,and equipment in Part X, line 10? If'Yes,'complete Schedule D, Part VI........................................................................................................ 11 a X b Did the organization report an amount for investments-other securities in Part X, line 12,that is 5%or more of its total assets reported in Part X, line 16? If'Yes,'complete Schedule D, Part VII............................................ 11 b X I c Did the organization report an amount for investments--program related in Part X, line 13,that is 5%or more of its total assets reported in Part X, line 16? If'Yes,'complete Schedule D, Part Vlll............ 11 c X i d Did the organization report an amount for other assets in Part X, line 15,that is 5%or more of its total assets reported in Part X, line 16? If'Yes,'complete Schedule D, Part IX.....................:...............................•...... 11 d X e Did the organization report an amount for other liabilities in Part X, line 25? If'Yes,'complete Schedule D, Part X...... lie X f Did the organization's separate or consolidated financial statements for the tax year include a footnote that addresses the organization's liability for uncertain tax positions under FIN 48(ASC 740)? If'Yes,'complete Schedule D, Part X.... 11 f X 12a Did the organization obtain separate,independent audited financial statements for the tax year? if'Yes,'complete Schedule D, Parts XI and XII..............................................................................:....... 12a X i b Was the organization included in consolidated, independent audited financial statements for the tax year? If'Yes,'and if the organization answered'No'to line 12a, then completing Schedule D,.Parts XI and XII is optional................. 12b X 13 Is the organization a school described in section 170(b)(1)(A)(ii)? If'Yes,'complete Schedule E....................... 13 X 14a Did the organization maintain an office, employees, or agents outside of the United States?........................... 14a X b Did the organization have aggregate revenues or expenses of more than$10,000 from grantmaking,fundraising, business,investment,and program service activities outside the United States,or aggregate foreign investments valued at$100,000 on more? If'Yes,'complete Schedule F, Parts 1 and 1V................................................... 14b X 15 Did the organization report on Part IX, column (A), line 3, more than$5,000 of grants or other assistance to or for any foreign organization? If'Yes,'complete Schedule F,Parts 11 and 1V.................................................. 15 X 16 Did the organization report on Part IX,column(A), line 3,more than$5,000 of aggregate grants or other assistance to or for foreign individuals? If'Yes,'complete Schedule F, Parts M and 1V.................... 16 X 17 Did the organization report a total of more than$15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11 e? If'Yes,'complete Schedule G, Part I(see instructions).................................. 17 X 18 Did the organization report more than$15,000 total of fundraising event gross income and contributions on Part Vill, lines 1c and 8a? If'Yes,'complete Schedule G, Part It...,.......................................................... 18 X 19 Did the organization report more than$15,000 of gross income from gaming activities on fart Vill, line 9a?If'Yes,', complete Schedule G, Part1I1....................................... ............................., 19 X 20a Did the organization operate one or more hospital facjlities? If'Yes,'complete Schedule H.... ............ 20a X b If'Yes'to line 20a, did the organization attach a copy of its audited financial statements to this return?................ 20b 21 Did the organization report more than$5,000 of grants or other assistance to any domestic organization or domestic government on Part IX,column (A), line 1? If'Yes,'complete Schedule 1,.Parts I and 11.........:............ 21 X BAA _.w._.. TEEA0103L 07131119. Form 990 (2019) Form 990 (2019) Asian Pacific American Page 4 P.aff IV 1 Checklist of Required Schedules (continued) Yes No 22 Did the organization report more than$5,000 of grants or other assistance to or for domestic individuals on Part 1X, column (A), line 2? If'Yes,'complete Schedule 1, Parts I and III..................................................... 22 X 23 Did the organization answer'Yes'to Part VII,Section A, line 3,4,or 5 about compensation of the organization's current and former officers,directors,trustees,key employees, and highest compensated employees? If'Yes,'complete ScheduleJ................. ................................................................................. 23 X 24a Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than$100,000 as of the last day of the year, that was issued after December 31,2002? If'Yes,'answer lines 246 through 24d and complete Schedule K. If'No, 'go to line 25a............ ......... 24a X .................................................... b Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?.................. 24b c Did the organization maintain an escrow account other than a refunding escrow at any time during the year to defease any tax-exempt bonds?.......................................:.................................................... 24c d Did the organization act as an 'on behalf of issuer for bonds outstanding at any time during the year?................. 24d 25a Section 501(cx3),501(c)(4),and 501(c)(29)organizations.Did the organization engage in an excess benefit transaction with a disqualified person during the year? If'Yes,'complete Schedule L, Part 1........................... 25a X b Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year,and that the transaction has not been reported on any of the organization's prior Forms 990 or 990-EZ? If'Yes,'complete ScheduleL, Part ................................................................................................ 25b X 26 Did the organization report any amount on Part X, line 5 or 22,for receivables from or payables to any current or former officer,director, trustee, key empl0 ee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons. If'Yes,'complete Schedule L,Part tl..................................... 26 X 27 Did the organization provide a grant or other assistance to any current or former officer,.director,trustee, key employee,creator or founder, substantial contributor or employee thereof,a grant selection committee member, or to a 35% controlled entity(including an employee thereof)or family member of any of these persons? If'Yes,'complete Schedule L, Part III .................................................................... 27 X 28 Was the organization a party to a business transaction with one of the following parties(see Schedule L,Part IV instructions,for applicable filing thresholds,conditions,and exceptions): a A current or former officer,director,trustee, key employee, creator or founder, or substantial contributor? If 'Yes,'complete Schedule L, Part IV........................ .... 28a X b A family member of-any individual described in line 28a? If'Yes,'complete Schedule L, Part IV........................ 28b X c A 35%controlled entity of one or more individuals and/or organizations described in lines 28a or 28b? If Yes,'complete Schedule L, Part IV................................................................................. 28c X 29 Did the organization receive more than$25,000 in non-cash contributions? If'Yes,'complete Schedule M.............. 29 X 30 Did the organization receive contributions of art, historical treasures,or other similar assets,or qualified conservation contributions? If'Yes,'complete Schedule M.................................................................. 30 X 31 Did the organization liquidate,terminate, or dissolve and cease operations? If'Yes,'complete Schedule N, Part 1....,,,, 31 X I 32 Did the organization sell,exchange,dispose of,or transfer more than 25%of its net assets?If'Yes,'complete ScheduleN, Part .........................................::.................................................... 32 X 33 Did the organization own 100%of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If'Yes,'complete Schedule R, Part I...................................... 33 X 34 Was the organization related to any tax-exempt or taxable entity? If'Yes,'complete Schedule R, Part 11, 111, or IV, and Part V, line I................... ............................... ....... 34 X $5a Did the organization have a controlled entity within the meaning of section 512(b)(13)?................................ 35a X b If'Yes'to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If'Yes,'complete Schedule R, Part V, line 2.......................... 35b 36 Section 501(cx3)organizations.Did the organization make any transfers to an exempt non-charitable related organization? If'Yes,'complete Schedule R, Part V, line 2.........................................................: 36 X 37 Did the organization conduct more than 5%of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If'Yes,'complete Schedule!3'Part VI...................... 37 X 38 Did the organization complete Schedule 0 and provide explanations in Schedule 0 for Part VI, lines I I and 19? . Note: All Form 990 filers are required to complete Schedule O....................................................... 38 X Fart'V Statements Regarding Other IRS Filings and Tax Compliance Check if Schedule-0--contains a response or note to any line in this Part V.................................................... Yes No 1 a Enter the number reported in Box 3 of Form 1096. Enter-0- if not applicable.............. I lal 4 b Enter the number of Forms W-2G included in line 1a. Enter-0- if not applicable,.......... I IIIJI p c Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling)winnings to prize winners?.............................................................................. BAA Form 990 (2019) Form 990 (2019) Asian Pacific American Page 5 Pa,rtV.I Statements Regarding Other IRS Filings and Tax Compliance (continued) Yes No 2a Enter the number of employees reported on Form W-3,Transmittal of Wage and Tax State- ments,filed for the calendar year ending with or within the year covered by this return..... I 2a 3 b If at least one is reported on line 2a, did the organization file all required federal employment tax returns?............. 2 b X Note: If the sum of lines 1 a and 2a is greater than 250,you may be required to a-file(see instructions) 3a Did the organization have unrelated business gross income of$1,000 or more during the year?........................ 3a X b If'Yes,'has it filed a Form 990-T for this year?if'No'to line 3b,provide an explanation on Schedule 0................................. 3 b 4a At any time during the calendar year, did the organization have an interest in,or a signature or other authority over,a financial account in a foreign country (such as a bank account, securities account, or other financial account)?......... 4a X b If'Yes,'enter the name of the foreign country® ! See instructions for filing requirements for FinCEN Form 114,Report of Foreign Bank and Financial Accounts(FBAR). 5a Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?................... 5a X b Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?......... 5 b X c If'Yes,'to line 5a or 5b, did the organization file Form 8886-7...................................................... Sc 6a Does the organization have annual gross receipts that are normally greater.than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?.. .......................... 6 a X b Ino di he organization r ableZnizati n include with every solicitation an express statement that such contributions or gifts wore 6 h 7 Organizations taxd that may receive deductible contributions under section 170(c). a Did the organization receive a p ........................................ ..............ayment in excess of$75 made partly as a contribution and partly for goods and services provided to the payor................... ........... 7 a X . b if'Yes,'did the organization notify the donor of the value of the goods or services provided? ................... 7 b c Did the organization sell, exchange,or otherwise dispose of tangible personal property for which it was required to file Form8282. ...................................................................................................... 7 c X d If'Yes,' indicate the number of Forms 8282 filed during the year.......................... I 7 d e Did the organization receive any funds,directly or indirectly,to pay premiums on a personal benefit contract?.......... 7 e X f Did the organization, during the year, pay premiums,directly or indirectly, on a personal benefit contract?.............. 7 f I X g If the organization received a contribution of.qualified intellectual property, did the organization file Form 8899 asrequired?...................................................................................................... 7 g h If the organization received a contribution of cars, boats,airplanes,or other vehicles, did the organization file a Form1098=C?.................................................... .......... 7 h 8 Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the sponsoring ; organization have excess business holdirfgs at any time during the year?..............I.... ..................... 8 9 Sponsoring organizations maintaining donor advised funds. a Did the sponsoring organization make any taxable distributions under section 4966?................................... 9a b Did the sponsoring organization make a distribution to a donor, donor advisor, or related person?...................... 9b 10 Section 501(cx7)organiiations.Enter: a Initiation fees and capital contributions included on Part VIII, line 12...................... 10a b Gross receipts, included on Form 990, Part VIII, line 12,for public use of club facilities..... I 10b 11 Section 501(cx12)organizations.Enter: a Gross income from members or shareholders........... ............................... 11 a j E - b Gross income from other sources (Do not net amounts due or paid to other sources against amounts duo or received from them.)......................... .................. 11 b 12a Section 4947(a)(1)non-exempt charitable trusts.is the organization filing Form 990 in lieu of Form 1041Z.............. 12a b If'Yes,'enter the amount of tax-exempt interest received or accrued during the year....... I 12b 13 Section 501(cx29)qualified nonprofit health insurance issuers. a Is the organization licensed to issue qualified health plans in more than one state?................................... 13a Note:See the instructions for additional information the organization must report on Schedule 0. b Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans 13b c Enter the amount of reserves on hand....................................I............. I 13c 14a Did the organization receive any payments for indoor tanning services-during the tax year?............................ 14a X b If'Yes,' has it filed a Form 720 to report these payments? if'No,'provide an explanation on Schedule 0............... 14b 15 Is the organization subject to the section 4960 tax on payment(s)of more than $1,000,000 in remuneration or excess parachute payment(s)during the yoar?...................................................................... 15 X If'Yes,'see instructions and file Form 4720, Schedule N. 16 Is the organization an educational institution subject to the section 4968 excise tax on net investment income? 16 X If'Yes,'complete Form 4720, Schedule 0. "`l ,:` , BAA TEEA0105L 07/31119 Form 990 (2019) Form 990(2019) Asian Pacific American Page 6. Part:'VF Governance, Management, and Disclosure For each 'Yes'response to lines 2 through 7b below, and for a 'No'response to line 8a, 8b, or 10b below, describe the circumstances, processes, or changes on Schedule O. See instructions. I� Check if Schedule O contains a response or note to any line in this Part VI.................................................. LI Section A. Governing Body and Management Yes No 1 a Enter the number of voting members of the governing body at the end of the tax year...... 1 a 3 If there are material differences in voting rights among members i of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee,.explain on Schedule O. b Enter the number of voting members included on line 1 a, above,who are independent..... 1 b. 2 2 Did any officer,director,trustee,or key employee have a family relationship or a business relationship with any other officer, director, trustee,or key employee?......................................................................... 2 X ! 3 Did the organization delegate control over management duties customarily performed by or under the direct supervision ! of officers, directors,trustees,or key employees to a management company or other person?......................... a X 4 Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?................................................................................ 4 X 5 Did the organization become aware during the year of a significant diversion of the organization's assets?.............. 5 X I 6 Did the organization have members or stockholders?................................................................ 6 X 7 a Did the organization have members, stockholders,or other persons who had the power to elect or appoint one or more members of the governing body?..................................................... 7a X b Are any governance decisions of the organization reserved to(or subject to approval by) members, stockholders, or persons other than the governing body?............................................. ................ 7 b X 8 Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following: a The governing body?............................................................... ........ 8a X b Each committee with authority to act orr behalf of the governing body?............................................... 8 b X 9 Is there any officer, director, trustee, or'key employee listed in Part Vil, Section A, who cannot be reached at the organization's mailing address? If'Yes,'provide the names and addresses on Schedule 0............................ 9 X Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.) Yes No 10a Did the organization have local chapters, branches,or affiliates?..................................................... Joe X b If'Yes,'did the organization have written policies and procedures governing the activities of such chapters,affiliates,and branches to ensure their operations are consistent with the organization's exempt purposes?................................................................ 10 b 11 a Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?...................... 11 a X 7777 b Describe in Schedule O the process, if any, used by the organization to review this Form 990. See Schedule 0 12a Did the organization have a written conflict of interest policy? If'No,'go to line 13.................................... 12a X b Were officers,directors,or trustees,and key employees required to disclose annually interests that could give rise toconflicts?....................................................................................................... 12b c Did the organization regularly and consistently monitor and enforce compliance with the policy? if'Yes,'describe in Schedule O how this was done...................................................................•................. 12c 13 Did the organization have a written whi.stleblower policy?..... ....................................... 13 X 14 Did the organization have a written document retention and destruction policy?,.. ......... .................... 14 X 15 Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision? a The organization's CEO, Executive Director,or top management official..See.Schedule-0......................... 15a X b Other officers or key employees of the organization...See.Schedule..0.. 15b X If'Yes'to line 15a or 15b, describe the process in Schedule O (see instructions). 16a Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year?................................................... .................................. 16a X . b If'Yes,'did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization's exempt status with respect to such arrangements?......... .............................. I 161J Section C. Disclosure 17 List the states with which a copy of this Form 990 is required to be filed ► —CA ___________________________ 18 Section 6104 requires an organization to make its Forms 1023 (1024 or 1024-A, if applicable), 990, and 990-T(Section 501(c)(3)s only) available for public inspection. Indicate how you made these available.Check all that apply. 11 Own website Another's website 0 Upon request Other (explain on Schedule 0) 19 Describe on Schedule 0 whether(and if so,how)the organization made its governing documents,conflict of interest policy,and financial statements available to the public during the tax year. See Schedule 0 20 State the name,address,and telephone number of the person who possesses the organization's books and records ► Michael Chang Cupertino CA 95014 BAA TEEA0106L 07131119 Form 990(2019) Form 990 (2019) Asian Pacific American Page 7 Part Vll' Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors Check if Schedule O contains a response or note to any line in this Part VI1................................................. ❑ Section A. Officers, Directors,Trustees, Key Employees,and Highest Compensated Employees 1 a Complete this table for all persons required to be listed.Report compensation for the calendar year ending with or within the organization's tax year. • List all of the organization's current officers, directors,trustees (whether individuals or organizations), regardless of amount of compensation. Enter-0- in columns (D), (E),and (F) if no compensation was paid, • List all of the organization's current key employees, if any. See instructions for definition of'key employee.' • List the organization's five current highest compensated employees (other than an officer,director, trustee, or key employee) who received reportable compensation (Box 5 of Form W-2.and/or Box 7 of Form 1099-MISC) of more than $100,000 from the organization and any related organizations. • List all of the organization's former officers, key employees, and highest compensated employees who received more than $100,000 of reportable compensation from the organization and any related organizations. • List all of the organization's former directors or trustees that received,in the capacity as a former director or trustee of the organization, more than $10,000 of reportable compensation from the organization and any related organizations. See instructions for the order in which to list the persons above. ❑ Check this box if neither the organization nor any related organization compensated any current officer,director,or trustee. P Position do not check more ( ) than one(do unless person A B D) E) (F) Name and title Average is both an officer and a Reportable Reportable Estimaled amount hours directodtrustee) compensation from compensation from of other per the orgganization related organizations week + ° ? (W-211099-MISQ tW-211099-MISC} compensation from ra _ the organization hours for o and related related a organizations organiza-z _4 ' tions below dotted line) � a I (1) Michael Chang 10 j Executive Dir. 0 X 40,002. 0. 0. (2) Glenn Osaka 1 - -M ----------------------- Treasurer 0 X 1 0.1 0. 0. -(3) Paul-Fong------------------1- I Secretary 0 X 0. 0. 0. —(4)-----------... ——————————— -- - —(—r'}---------------------_--_-_-_ ———— (6) (7) (g) (9) (10) (11) ------------------------------ (12) ------------------------------ (13) (14) BAA TEEA0107L 07/31119 Form 990(2019) Form 990(2019) Asian Pacific American Page 8 Part Vil I Section A.Officers,Directors,`trustees, Key Employees,and Highest Compensated Employees(continued) (B) P Position D (A) Average (do not check more than one ( ) ( ) (F) Name and title hours box,unless person is both an Reportable Reportable Perk officer and a directorltrastee) compensation from compensation from Estimated amount week of other (list any 3 t� _ the orgganization mated orgganizations compensation from hours q_ (W-2l1D99-MlSC} (1N-2l1099-MISC) 3i -g the organization for and related related ` n w organizations organiza 3 -bons below <u dotted 3 ' line) (15) (16) (1 7) ------------------------------ (18) 1 (19) (20) (21) ------------.—....................... --_-- ---- (2 -- (23) (24) (25) 1 b Subtotal................................................................. ■ 40,002. 0. 0. c Total from continuation sheets to Part VII,Section A....................... 0. 0. 0. d Total(add lines 1b and 1c)................... ............... 40,002. 0. 0. 2 Total number of individuals(including but not limited to those listed above)who received more than$100,000 of reportable compensation. from the organization ■ 0 Yes No 3 Did the oanization list any former officer, director, trustee, key employee, or highest compensated employee on line 12 If'Yes,'complete Schedule J for such individual......... .... 3 X I 4 For any individual listed on line la, is the sum of reportable compensation and other compensation from I the organization and related organizations greater than $150,000? If'Yes,'complete Schedule J for ! such individuall......................................... 5 Did any person listed on line la receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? if'Yes,'complete Schedule J for such person............................... 5 ' X j Section B. Independent Contractors Complete this table for your five highest compensated independent contractors that received more than$100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization's tax year. Name and business address DescriptionBof services Compensation 2 Total number of independent contractors(including but not limited to those listed above)who received more than $100,000 of compensation from the organization■ 0 BAA TEEA0108L 07/31119 Form 990 (2019) Form 990(2019) Asian PaCifiC American Page 9 Part:`1111 Statement of Revenue Check if Schedule 0 contains a response or note to any line in this Part VIII................................................. A B C D Total revenueRelated or Unrelated Revenue exempt business excluded from tax function revenue under sections revenue 512.514 . 7 a Federated campaigns......... la #�. b Membership dues............. 7 b c Fundraising events............ 1 c 't d Related organizations......... 1 d e Government grants(contributions).... le It f All other contributions,gifts,grants,and m similar amounts not included above... if 346 145 g Noncasb contributions included in i 7 �.,.... lines 1a-1f...................... 9 , c :w h Total.Add lines 1a-11............. ° 346 145. € Business Code 2a Leadership Program Fee— 5 349. 5 349. Cr b qtC ------------------ N ———— ——————————— E e of All other program service revenue,. IL` g Total.Add lines 2a-2f................ ° 5,349. 3 Investment income(including dividends, interest,and other similar amounts).............................. > 179. 179. 4 Income from investment of tax-exempt bond proceeds..P 5 Royalties........................ . (i)Real (ii)Personal 6a Gross rents........ 6A le Less,rental expenses 6b c Rental income or(loss) 6c d Net rental income or(loss)....... ... 7 a Gross amount from (i)securitieess {ii}Other sales of assets other than invontory 7a le Less:cost or other basis and sales expenses 7b 1 c Gain or(loss)...... 7c d Net gain or(loss)................................... 8 a Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV,line 18.........,.. 8a b Less: direct expenses...... 810 c Net income or(loss)from fundraising events......... 9a Gross income from gaming activities. See Part IV,line 19............ 9a b Less: direct expenses...... 9b c Net income or(loss)from gaming activities........... ► 10a Gross sales of inventory,less..... returns and allowances 0a b Less: cost of goods sold-... 0b c Net income or(loss)from sales of inventory...... ,. ► Business Code -- p77a __________________ 2 b ------------------ c d All other revenue .... ....... ... . e Total.Add lines 11a-1 Id............ •................ -. 3 72 Total revenue.See instructions...................... ° 351 673. 5 528. 0. 0. BAA TEEA0109L 07/31119 Form 990(2019) Form 990(2019) Asian Pacific American Page 10 Put IX: I Statement of Functional Expenses Section 501(c)(3)and 501(c)(4)organizations must complete all columns,All other organizations must complete column(A). Check if Schedule O contains a response or note to any line in this Part IX............................................ Do not Include amounts reported on lines A B C D A Total expenses Program service Management and Fundraising 6b,7b,8b,9b,and 10b of Aar! Vlll. expenses general expenses expenses 1 Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21....................... 2 Grants and other assistance to domestic individuals, See Part IV, line 22............ 3 Grants and other assistance to foreign organizations,foreign governments,and for- eign individuals. Soe Part IV, lines 15 and 16 4 Benefits paid to or for members............ 5 Compensation of current officers, directors, trustees,and key employees.............. 40,002. 32,002. 8,000. 0. 6 Compensation not included above to disqualified persons(as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(8).................... 0. 0. 0. 0. 7 Other salaries and wages.................. 77,094. 61,675. 15,419. 8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions).................:.. 9 Other employee benefits................... 10 Payroll taxes............................... 9,809. 7,847. 1, 962. 11 Fees for services(nonemployees): a Management.............................. bLegal..................................... 3 260. 3,260. c Accounting................................ dLobbying................................ e Professional fundraising services.See Part IV,line 17... f Investment management fees.............. g Other.(If line 11g amount exceeds 10%of line 25,column (A)amount,list line 11g expenses on Schedule 0.)..... 12 Advertising and promotion.................. 4,428. 2,214. 2,214. 13 Office expenses.............. 8,372. 4,186. 4,186. 14 Information technology................... 15 Royalties... ....... .......... 16 Occupancy.. ....... ................. 17 Travel..................................... 154. 154. 18 Payments of travel or entertainment expenses for any federal, state, or local public officials............................. 19 Conferences, conventions,and meetings.... 20 Interest.................................... 21 Payments to affiliates...................... 22 Depreciation, depletion, and amortization.... 23 Insurance.......:......................... 4,100. 2,050. 2, 050. 24 Other expenses. Itemize expenses,not covered above (List miscellaneous expenses on lino 24e. If lino 24e amount exceods 10% of line 25,column (A)amount, list line 24e expenses on Schedule 0. a Gala_ _____ ' ___ _____ 17,310. 5,193. 12,117. b Program _r 15 839. 16 839. c --------------------- e All other expenses......................... 25 Total functional expenses.Add lines 1 through 24e.... 181,368. 132,006. 37,245. 12,117. 26 Joint costs.Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here ■ 0 if following SOP 98-2 (ASC 958-720)..:................ BAA TEEA0110L 07/31119 Form 990(2019) Form 990(2019) Asian Pacific American Page 11 earl-X- Balance Sheet- Check if Schedule O contains a response or note to any line in this Part X..........................•....................... El A S) Beginning of year End ofyear 1 Cash—non-interest-bearing.................................................. 54,235. 1 111,482. 2 Savings and temporary cash investments.... ............................... 267,287. 2 382,466. 3 Pledges and grants receivable, net............................................ 3 4 Accounts receivable, net...................................................... 4 5 Loans and other receivables from any current or former officer, director, 1 trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons..................... 5 6 Loans and other.receivables from other disqualified persons (as defined under '� section 4958(f)(1)), and persons described in section 4958(c)(3)(B)............. 6 7 Notes and loans receivable, net............. 7 d 8 Inventories for sale or use...................... ............................. 8 9 Prepaid expenses and deferred charges....................................... 9 10a Land, buildings, and equipment:cost or other basis. Complete Part VI of Schedule D............. 10a b Less: accumulated depreciation.................... 10b 10c 11 Investments —publicly traded securities......... 11 12 Investments --other securities.See Part IV, line 11................ 12 I 13 Investments --program-related. See Part IV, line 11.........I.................. 13 14 Intangible assets...................................................I......... 14 15 Other assets. See Part IV, line 11............................................. 15 16 Total assets.Add lines 1 through 15 (must equal Iine.33)........................ 321,522. 16 493, 948. 17 Accounts payable and accrued expenses...................................... 17 18 Grants payable.............................................................. 18 19 Deferred revenue............................................................ 19 20 Tax-exempt bond liabilities................................................... 20 21 Escrow or custodial account liability.Complete Part IV of Schedule D........... 21 22 Loans and other payables to any current or former officer,director, trustee, key employee., creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons..................... 22 23 Secured mortgages and notes payable to unrelated third parties................ 23 24 Unsecured notes and loans payable to unrelated third parties................... 24 25 Other liabilities (including federal income tax, ppayables to related third parties, and other liabilities not included on lines 17.24). Complete Part X.of Schedule D. 1,657. 25 3,778. 26 Total liabilities,Add lines 17 through 25....................................... 1,657. 26 3,778.0 0 Organizations that follow FASB ASC 958,check here and complete lines 27,28,32,and 33. 27 Net assets without donor restrictions.......................................... 27 W 28 Net assets with donor restrictions............................................. 28 Organizations that do not follow FASB ASC 958,check here L and complete lines 29 through 33. 29 Capital stock or trust principal,or current funds.',.............................. 29 4 30 Paid-in or capital surplus, or land, building, or equipment fund................... 30 1 31 Retained earnings, endowment, accumulated income,or other funds............ 319,865. 31 •490,170. 32 Total net assets or fund balances............................................. 319,865. 32 490,170. Z 33 Total liabilities and net assetslfund balances_ .......... 321,522. 33. 493, 948. BAA TEEA0111L oMili5 Form 990(2019) Form 990(2019) Asian Pacific American Page 12 Pert XI' Reconciliation of Net Assets Check if Schedule O contains a response or note to any line in this Part XI.................................................. Fl- 1 Total revenue (must equal Part VIII, column (A), line 12)................................................. 1 351 673. 2 Total expenses (must equal Part IX, column (A), line 25)................................................. 2 181,368. 3 Revenue less expenses. Subtract line 2 from line 1 ....................................................... 3 170,305. 4 Net assets or fund balances at beginning of year(must equal Part X, line 32, column (A)).................. 4 319, 865. 5 Net unrealized gains (losses) on investments.:........................................................... 5 6 Donated services and use of facilities................................................................... 6 7 Investment expenses..........................................................----............... 7 8 Prior period adjustments............................................................................... 8 9 Other changes in net assets or fund balances(explain on Schedule 0).................................... 9 0. 10 Net assets or fund balances at end of year.Combine lines 3 through 9(must equal Part X, line 32, column (B))........................................................................................... 10 490 1.70. PartXil� Financial Statements and Reporting Check if Schedule 0 contains a response or note to any line in this Part XI ................................................. Yes No 1 Accounting method used to prepare the Form 990; M Cash Accrual Other If the organization changed its method'of accounting from a prior year or checked 'Other,'explain in Schedule O. 2a Were the organization's financial statements compiled or reviewed by an independent accountant?.................... 2a X If'Yes,'check a box below to indicate whether the financial statements for the year were compiled or reviewed on a se arate basis, consolidated basis, or both; Separate basis Consolidated basis 11 Both consolidated and separate basis b Were the organization's financial statements audited by an independent accountant?.................................. 2 b X If'Yes,'check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both: Separate basis Consolidated basis Both consolidated and separate basis c If'Yes'to line 2a or 2b,does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?........................ 2c If the organization changed either its oversight process or selection process during the tax year, explain on Schedule O, 3 a As a result of a federal award,was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?.....................................:.......................................... 3 a X b If'Yes,'did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why on Schedule O and describe any steps taken to undergo such audits........................... 3 b. BAA TEEA0112L 01/21120 Form 990(2019) { j 1 1 OMB No.1545-0047 SCHEDIJI A Public Charity Status and Public Support (Form 990 or 990-EZ) Complete if the organization is a section 507(c)(3)organization or a section 2019 4947(a)(1)nonexempt charita��lle trust. o Attach to Form 990 or Form 990-EZ. Operi to Public I Zan'ment of the Treasury o Go to www.frs. ov/Form990 for instructions and the latest information. Ins ection . Internal Revenue Service g . P. Name of the organtzatlon Asian Pacific American Employer ldentificatlonnumber Leade.rsha institute Part1.1- Reason far Public Charity Status(All organizations must complete this part.) See instructions. The organization is not a private foundation because it is: (For lines 1 through 12, check only one box.) 1 A church,convention of churches,or association of churches described in sedIOD 170(h)(1)(A)(I). 2 A school described in section 170(b)(1XA)(ii).(Attach Schedule E(Form 990 or 990-EZ).) 3 A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(1ii). 4 A medical research organization operated in conjunction with a hospital described in section 170(6)(1)(A)(iii). Enter the hospital's name, city, and state: --------------------------------------------------- 5 An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(Axiv). (Complete Part Il.) 6 A federal,state, or local government or governmental unit described in section 170(b)(1)(A)(v). 7 An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(bx1XA)(vi). (Complete Part 11.) 8 ❑A community trust described in section 170(h)(1XAxvi). (Complete Part 11.) 9 An agricultural research organization described in section 170(b)(1)(A)(ix)operated in conjunction with a land-grant college or university or a non-land-grant college of agriculture(see instructions).Enter the name,city,and state of the college or university; --------------^� i 10 ❑x An organization that normally receives: (1)more than 33-113%of its support from contributions, membership fees,and gross receipts j from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 33-113%of its support from gross investment income and unrelated business taxable income (less section 511 tax)from businesses acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part lit.) 11 An organization organized and operated exclusively to test for public safety. See section 509(ax4). 12 An organization organized and operated exclusively for the benefit of,to perform the functions of,or to carry out the purposes of one or more publicly supported organizations-described in section 509(aX.1)or section 509(a)(2). See section 509(ax3). Check the box in j lines 12a through 12d that describes the type of supporting organization and complete)lines 12e, 12f, and 12g. a Type I.A supporting organization operated,supervised, or controlled by its supported.organization(s),typically by giving the supported organization(s)the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization.You must complete Part IV,Sections A and B. b 0 Type II.A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supppporting organization vested in the same persons that control or manage the supported organization(s).You must complete Part IV,Sections A and C. c Type III functionally integrated.A supporting organization operated in connection with,and functionally integrated with,its supported organization(s) (see instructions). You must complete Part IV,Sections A,D,and E. d Type III non-functionally integrated.A supporting organization operated in connection with its supported organization(s)that is not functionally integrated.The organization generally must satisfy a distribution requirement and an attentiveness requirement(see instructions).You must complete Part IV,Sections A and D,and Part V. e Check this box if the organization received a written determination from the IRS that it is a Type I,Type II,Type III functionally Integrated,or Type III non-functionally integrated supporting organization. f Enter'the number of supported organizations........................................................................ g Provide the following information about the supported organization(s). (1)Name of supported organization 00 EIN ((Ili)Type of organization (Iv)Is the (v)Amount of monetary (vi)Amount of other (described on lines 1-10 organization listed support(see instructions) supped(see instructions) above(see instructions)) in your governing document? Yes No (A) (B) (C) (D) (E) Total BAA For Paperwork Reduction Act Notice,see the Instructions for Form 990 or 990-EZ. Schedule A(Form 990 or 990-EZ)2019 TEEA0401L 0710al19 - Schedule A(Form 990 or 990-EZ)2019 Asian Pacific American Page 2 Part llj Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv)and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5,7,or 8 of Part I or if the organization tailed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.) Section A. Public Support Calendar year(or fiscal year (a)2015 (b)2016 (c)2017 (d)2018 (e)2019 (f)Total beginning in) 1 Gifts,grants,contributions,and membership fees received.(Do not include any'unusual grants.)........ 2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.................. 3 The value of services or facilities furnished by a governmental unit to the organization without charge, . 4 Total.Add lines 1 through 3... 5 The portion of total . contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2%of the amount shown on line 11, column (f)... 6 public support.Subtract line 5 from line 4................... a Section B.Total Support Calendar year(or fiscal year (a)2015 (b)2016 (c)2017 (d)2018 (e)2019 (f)Total beginning in) 7 Amounts from line 4.......... 8 Gross.income from interest, dividends, payments received on securities loans, rents, royalties, and income from similar sources............... 9 Net income from unrelated business activities, whether or not the business is regularly carried on.................... 10 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part Vl.)..................... 11 Total support.Add lines 7 through 1Q................ 12 Gross receipts from related activities, etc..(see instructions)................ ................ . 12 i 13 First five years.If the Form 990 is for the organization's first,second,third,fourth,or fifth tax year as a section 501(c)(3) ❑ organization,check this box and stop here.................................................................................... Section C. Computation of Public Support Percentage 14 Public support percentage for 2019(line 6, column (f) divided by line 11,column (f))............................ 14 % 15 Public support percentage from 2018 Schedule A, Part II, line 14............................................. 15 % 1 16a 33.1t3%support test-2019. If the organization did not check the box on line 13, and line 14 is 33 113%or more, check this box ❑ and stop here.The organization qualifies as a publicly supported organization................................................... b 33-113%a support test-2018. If the organization did not check a box on line 13 or 16a, and line 15 is 33-113%or more, check this box ❑ and stop here.The organization qualifies as a publicly supported organization.................................................. 17a 10%-facts-and-circumstances test-2019.If the organization did not check a box on line 13, 16a, or 16b, and line 14 is 10% or more, and if the organization meets the 'facts-and-circumstances'test,check this box and stop here.Explain in Part VI how ❑ the organization meets the'facts-and-circumstances'test. The organization qualifies as a publicly supported organization.......... b 10%-facts-and-circumstances test-2018.If the organization did not check a box on line 13, 16a, 16b, or 17a, and line 15 is 10% or more,and if the organization meets the 'facts-and-circumstances' test, check this box and stop here.Explain in Part VI how the organization meets the'facts-and-circumstances'test.The organization qualifies as a publicly supported organization.............. H 18 private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b,check this box and see instructions... BAA Schedule A(Form 990 or 990-EZ)2019 TEEAM02L- 07103119 Schedule A(Form 990 or 990-EZ)2019 Asian Pacific American Page 3 Par."fall Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part If. If the organization fails to qualify under the tests listed below, please complete Part Il.) Section A. Public Support Calendar year(or fiscal year beginning In)► (a)2015 (b)2016 (c)2017 (d) 2018 (e)2019 (f)Total 1 Gifts, grants, contributions, and membership fees received. (Do not include any'unusual grants.')......... 198 213. 276 532. 346 145. 820, 890. 2 Gross receipts from admissions, merchandise sold or services performed,or facilities furnished in any activity that is related to the organization's tax-exempt purpose........... 4,402. 4,734. 5,349. 14,485, 3 Gross receipts from activities that are not an unrelated trade or business under section 513. 0 4 Tax revenues levied for the organization'sbenefit and either paid to or expended on its behalf................. 5 The value of services or 0' facilities furnished by a governmental unit to the organization without charge... 0 6 Total.Add lines 1 through 5... 0. 0. 202 615. 281 266. 351 494. 835,375. 7a Amounts included on lines 1, 2, and 3 received from disqualified persons........... 0. 0. 0. 0. 0. 0. b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of$5,000 or 1%'of the amount on line 13 for the year..................... 0. 0. 0. 0. 0. 0. I c Add lines 7a and 7b........... 0.1 0. 0.1 0.1 0.1 0. 8 Public support.(Subtract line E7c from line 6.)............... - 835 375. Section B.Total Support Calendar year(or fiscal year beginning in) (a)2015 (b)2016 (c)2017 (d)2018 (o)2019 (f)Total 9 Amounts from line-6.......... 0. 0. 202, 615. 281,266. 351 494. 835,375. 10a Gross income from.interest,dividends, payments received on securities loans, rents,royalties,and income from similar sources.................. 0 b Unrelated business taxable income (less section 511 taxes)from businesses acquired after June 30, 1975... 0 c Add lines 10a and 10b........ 0. 0. 0. 0. 0. 0. 11 ,Net income from unrelated business activities not included in line 10b, whether or nut the business is regularly carried on..... 0. 12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.)..................... 0. 13 Total support. (Add lines 9, 1oc, 11, and 12.)............. 0. 0. 202,615. 281,266. 351,494. 835,375. 14 First five years. If the Form 990 is for the organization's first, second, third,fourth, or fifth lax year as a section 501(c)(3) organization, check this box and stop here,;.................................... ............................... � ❑ Section C. Computation of Public Support Percentage 15 Public support percentage for 2019 (line 8,column (0, divided by line 13, column (f)) 15 16 Public support percentage from 2019 Schedule A, Part III, line 15............................................. 16 0 Section D.Computation of Investment Income Percentage 17 Investment income percentage for 2019(line 10c, column (f), divided by line 13, column (f)).................... 17 18 Investment income percentage from 2018 Schedule A, Part III, line 17......:.......... ....... 18 0 19a 33-113%support tests-2019. If the organization did not check the box on line 14, and line 15 is more than 33-113%, and line 17 ❑ is not more than 33.113%, check this box and stop here.The organization qualifies aS a publicly supported organization........... b 33-113%support tests--2018. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33-1/3%, and line 18 is not more than 33-1/3%, check this box and stop here.The organization qualifies as a publicly supported organization.... i a 20 Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions............ RAA TEEA0403L 07/03/19 Schedule A(Form 990 or 990-EZ)2019 Schedule A(Form 990 or 990-EZ)2019 Asian Pacific American Page 4 Part IV . Supporting Organizations (Complete only if you checked a box in line 12 on Part I. If you checked 12a of Part.1, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d of Part I, complete Sections A and D, and complete Part V.) Section A.All Supporting Organizations Yes No 1 Are all of the organization's supported organizations listed by name in the organization's governing documents? if No,'describe in Part Vl how the supported organizations are designated. If designated by class or purpose, describe the designation. If historic and continuing relationship, explain.. 7 2 Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or(2)? If'Yes,'explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1)or(2). 2 j 3a Did the organization have a supported organization described in section 501(c)(4), (5),or(6)7 If'Yes,'answer(b) and'(c)below. - 3a b Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or(6)and } satisfied the public support tests under section 509(a)(2)? If'Yes,'describe in Part.V1 when and how the organization made the determination. 3b c Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) - I purposes? If'Yes,'explain in Part V1 what controls the organization put in place to ensure such use. 3c 4a Was any supported organization not organized in the United States ('foreign supported organization')? If'Yes'and A x if you checked 12a or 72b in Part 1, answer(b)and(c)below. 4a b Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If'Yes,'describe in Part VI how the organization had such control and discretion despite being controlled j or supervised by or in connection with its supported organizations. 4b C Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3)and 509(a)(1)or(2)? If'Yes,'explain in Part Vl what controls the organization used to ensure that - all support to the foreign supported organization was used exclusively for section 170(c)(2)(8).purposes. 4c 5a Did the organization add, substitute, or remove any supported organizations during the tax year? lf'Yes,'answer(b) and(c)below(if applicable).Also,provide detail in Part V1, including(i)the names and EIN numbers of the supported organizations added, substituted, or removed; (ii)the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action;and(iv)how the action was accomplished(such as by amendment to the organizing document). 5a b Type I or Type II only.Was any added or substituted supported organization part of a class already designated in the -' organizations organizing document? 5b c Substitutions only.Was the substitution the result of an event beyond the organization's control? 5c 6 Did the organization provide support(whether in the form of grants or the provision of services or facilities)to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations,or(iii)other supporting organizations that also support or benefit one or more of the filing organization's supported organizations? If'Yes,'provide detail in Part VI. 6 7 Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (as defined in section 4958(c)(3)(C)), a family member of a substantial contributor,or a 35%controlled entity with regard to a substantial contributor? !f'Yes,'complete Part I of Schedule I. (Form 990 or 990•EZ). 7 8 Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If'Yes,' complete Part I of Schedule L (Form 990 or 990-EZ). 8 9a Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946(other than foundation managers and organizations described in section 509(a)(1)or (2))? If'Yes,'provide detail in Part V1. 9a b Did one or more disqualified persons(as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If'Yes,'provide detail in Part VT 9b c Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, - assets in which the supporting organization also had an interest? If'Yes,'provide detail in Part Vl. 9c 10a Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type ll supporting organizations, and all Type III non-functionally integrated supporting organizations)? If'Yes,' answer 10b below. 10a b Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings.) 10b BAA TEEA0404L 07/03/19 Schedule A(Form 990 or 990-BZ)2019 Schedule A(Form 990 or 990-EZ)2019 Asian Pacific' American Page 5 Part IV I Supporting Organizations (continued) Yes No 11 Has the organization accepted a gift or contribution from any of the following persons? in A person who directly or indirectly controls,either alone or tpgether with persons described in (b)and(c) below,the governing body of a supported organization? • 11 a b A family member of a person described in (a)above? 11 b c A 35% controlled entity of a person described in (a)or(b) above? If'Yes'to a, b, or c, provide detail in Part V1. 11c Section B.Type I Supporting Organizations Yes No 1 Did the directors,trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization's directors or trustees at all times during the tax year? If'No,'describe in Part V1 how the supported organization(s)effectively operated, supervised, or controlled the organization's activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, , applied to such powers during the tax year. 1 2 Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? if'Yes,'explain in Part Vl how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised, or controlled the { supporting organization. 2 Section C. Type II Supporting Organizations Yes No i 1 Were a majority of the organization's directors or trustees during the tax year also a majority of the directors or trustees ' of each of the organization's supported organization(s)? If'No,'describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s). 1 j Section D. All Type III Supporting Organizations Yes No 1 Did the.organization provide to each of its supported organizations, by the last day of the fifth month of the organization's tax year, (i) a written notice describing the type.and amount of support provided during the prior tax year, (ii)a copy of the Form 990 that was most recently filed as of the date of notification, and (iii)copies of the organization's governing documents in effect on the date of notification, to the extent not previously provided? 1 2 Were an yy of the organization's officers, directors, or trustees either(i)appointed or elected by the supported organizations)or (ii) serving on the governing body of a supported organization? If'No,'explain in Part V1 how the organtzattion maintained a close and continuous working relationship with the supported organrzation(s). 2 3 By reason of the relationship described in (2), did the organization's supported organizations have a significant voice in the organization's investment policies and in directing the use of the organization's income or assets at all times during the tax year? if'Yes,'describe in Part W the role the organization's supported organizations played 1 in this regard. 3 Section E.Type III Functionally Integrated Supporting Organizations 1 Check the box next to the method that the organization used to satisfy the Integral Part Test during the year(see instructions). j a ❑ The organization satisfied the Activities Test. Complete line 2 below, b ❑ The organization is the parent of each of its supported organizations. Complete line 3 below. c ❑ The organization supported a governmental entity. Describe in Part W how you supported a government entity(see instructions). 2 Activities Test.Answer(a)and(b)below. Yes FNo a Did substantially all of the organization's activities during the tax year directly further the exempt purposes of the supported organization(s)to which the organization was responsive? if'Yes,'then in Part W identify those supported j organizations and explain how these activities directly furthered their exempt purposes, how the organization was 1 responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities. Za b Did the activities described in (a)constitute activities that, but for the organization's involvement, one or more of the organization's supported organization(s)would have been engaged in? If'Yes,'explain in Part V1 the reasons for the organization's position that its supported organization(s) would have engaged in these activities but for the organization's involvement, 2b 3 Parent of Supported Organizations.Answer(a)and(b)below. a Did the organization have the power to regularly appoint or elect a majority of the officers, directors,or trustees of each of the supported organizations? Provide details in Part V1. 3a b Did the organization exercise a substantial degree of direction over the policies,programs,and activities of each of its supported organizations? If'Yes,'describe in Part Vl the role played by the organization in this regard. 3b BAA TEEA0405L 07/03/19 Schedule A(Form 990 or 990-EZ)2019 Schedule A(Form 990 or 990-EZ)2019 Asian Pacific .American � Page 6 PAr V." Type III Non-Functionally Integrated 509(aX3)Supporting Organizations 1 Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970 (explain in Part VI). See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E. Section A—Adjusted Net Income (A)Prior Year (B) Current Year (optional) 1 Net short-term capital gain 1 _ 2 Recoveries of prior-year distributions 2 3 Other gross income(see instructions) 3 4 Add lines 1 through 3. 4 5 Depreciation and depletion 5 I 6 Portion of operating expenses paid or incurred for production or collection of gross I income or for management, conservation, or maintenance of property held for production of income(see instructions) 6 j 7 Other expenses (see instructions) 7 1 i 8 Adjusted Net Income (subtract lines 5, 6, and 7 from line 4) 8 Section B — Minimum Asset Amount (A)Prior Year (B) Current Year (optional) 1 Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): a Average monthly value of securities 1a b Average monthly cash balances 1 b c Fair market value of other non-exempt-use assets 1 c d Total (add fines 1 a, 1 b, and 1 c) 1 d e Discount claimed for blockage or other factors(explain in detail in Part VI): 2 Acquisition indebtedness applicable to non-exempt-use assets 2 3 Subtract line 2 from line 1d. 3 4 Cash deemed held for exempt use. Enter 1-112% of line 3 (for greater amount, see instructions). 4 5 Net value of non-exempt-use assets (subtract line 4 from line 3) 5 6 Multiply line 5 by.035, 6 7 Recoveries of prior year distributions 7 8 Minimum Asset-Amount(add line 7 to line 6) 8 Section C — Distributable Amount Current Year 1 Adjusted net income for prior year(from Section A, line 8, Column A) 1 2 Enter 85% of line 1. 2 3 Minimum asset amount for prior year(from Section B, line 8, Column A) 3 i 4 Enter greater of line 2 or line 3. 4 5 Income tax imposed in prior year 5 6 Distributable Amount.Subtract line 5 from line 4,unless subject to emergency temporary reduction (see instructions). 6 7 Check here if the current year is the organization's first as a non-functionally integrated Type III supporting organization (see instructions). BAA Schedule A(Form 990 or 990-EZ)2019 TEEAW6L 07103119 Schedule A(Form 990 or 990-EZ)2019 Asian Pacific American Page 7 Kart V Type III Non-Functionally Integrated 509(a)(3)Supporting Organizations (continued) Section D— Distributions current Year 1 Amounts paid to supported organizations to accomplish exempt purposes 2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity 3 Administrative expenses paid to accomplish exempt purposes of supported organizations 4 Amounts paid to acquire exempt-use assets 5 Qualified set-aside amounts (prior IRS approval required) 6 Other distributions(describe in Part VI). See instructions. 7 Total annual distributions.Add lines 1 through 6, 8 Distributions to attentive supported organizations to which the organization is responsive(provide details in Part VI). See instructions. 9 Distributable amount for 2019 from Section C, line 6 10 Line 8 amount divided by line 9 amount 0) (1I) (III) Section E — Distribution Allocations(see instructions) Excess Underdistributions Distril�iltable Distributions Pre-2019 Ainount for 2019 1 Distributable amount for 2019 from Section C, line 6 2 Underdistributions, if any,for years prior to 2019 (reasonable cause required —explain in Part VI). See instructions. 3 Excess distributions carryover, if any, to 2019 a From 2014................ b From 2015..... c From 2016. d From 2017... e From 2018.......... f Total of lines 3a through e { 9 Applied to underdistributions of prior years h Applied to 201.9 distributable amount { i Carryover from 2014 not applied (see instructions) i Remainder. Subtract lines 3g, 3h, and 3i from 3f. 4 Distributions for 2019 from Section D, line 7: a Applied to underdistributions of prior years b Applied to 2019 distributable amount c Remainder. Subtract lines 4a and 4b from 4. 5 Remaining underdistributions for years prior to 2019, if any. Subtract lines 3g and 4a from line 2. For result greater than j zero, explain in Part VI. See instructions. 6 Remaining underdistributions for 2019.Subtract lines 3h and 4b from line 1. For result greater than zero, explain in Part VI. See instructions. 7 Excess distributions carryover to 2020.Add lines 3j and 4c, 8 Breakdown of line 7; a Excess from 2015....... b Excess from 2016....... c Excess from 201 Z...... d Excess from 2018..... e Excess from 2019....... BAA Schedule A(Form 990 or 990-EZ)2019 TEEA0407L 07103fI9 Schedule A(Form 990 or 990-EZ)2019 Asian Pacific American Page 8 Part VI Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b-Part III, line 12; Part IV, Section A, lines 1, 2,3b,3c,4b,4c, 5a,6, 9a,9b, c, I la, 11b,and I Ic; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV,Section E, lines 1c,2a, 2b,3a, and 3b; Part V, line 1; Part V, Section B, line.1e; Part V, Section D, lines 5,6, and 8; and Part V,Section E, lines 2, 5,and 6.Also complete this part for any additional information. (See instructions.) F • I l i I BAA TEEAD408L 071U19 Schedule A(Form 990 or 990-EZ)2019 Schedule B OMB No.1545-0047 (Form 990,990-EZ, Schedule..of Contributors or 990-PF) ► Attach to Form 990,Form.990-EZ,or Form 990-PF. 2019 Department of the Treasury Internal Revenue service o Go to wwwdrs.gov/Form990 for the latest information. Name of the organization Asian Pacific, American Employer identification number Leadership I.nstai.tute Organization type(check one): Filers of: Section: Form 990 or 990-EZ 0 501(c)( 3 ) (enter number) organization ❑ 4947(a)(1) nonexempt charitable trust not treated as a private foundation Form 990-PF ❑ 527 political organization ❑ 501(c)(3)exempt private foundation ❑ 4947(a)(1) nonexempt charitable trust treated as a private foundation ❑ 501(c)(3)taxable private foundation Check if your organization is covered by the General Rule or a Special Rule. Note:Only a section 501(c)(7), (8), or(10)organization can check boxes for both the General Rule and a Special Rule. See instructions.- General Rule ❑X For an organization filing Form 990,990-E7-, or 990-PF that received,during the year,contributions totaling$5,000 or more(in money or property)from any one contributor,Complete Parts I and 11.See instructions for determining a contributor's total contributions. Special Rules I ❑ For an organization described in section 501(c)(3)filing Form 990 or 990-EZ that met the 33-1{3%support test of the.regulations under sections 509(a)(1)and 170(b)(1)(A)(vi),that checked Schedule A(Form 990 or 990-EZ),Part Il, line 13, 16a,or 16b,and that received from any one contributor, during the year, total contributions of the greater of(1)$5,000; or(2)2% of the amount on (i) Form 990, Part Vill, line 1h; or (ii) Form 990-EZ, line 1. Complete Parts I and II. I ❑ For an organization described in section 501(c)(7), (8), or(10)filing Form 990 or 990-EZ that received from any one contributor, during the year, total contributions of more than$1,000 exclusively for religious, charitable,scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, ll, and III, ❑ For an organization described in section 501(c)(7), (8), or (10)filing Form 990 or 990-EZ that received from any one contributor; during the year, contributions exclusively for religious,Charitable, etc., purposes, but no such contributions totaled more than $1,000. .If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Don't complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling$5,000 or more during the year. $ Caution:An organization that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B (Form 990,990-EZ, or 990-PF), but it must answer'No'on Part IV, line 2,of its Form 990; or check the box on line H of its Form 990-EZ or on its Form 990-PF, Part I, line 2, to certify that it doesn't meet the filing requirements of Schedule 13 (Form 990,990•EZ, or 990-PF). BAA For Paperwork Reduction Act Notice,see the Instructions for Form 990,990-EZ,or 990-PF. Schedule B(Form 990,990-EZ,or 990-PF)(2019) TEEA0701L 08/09/19 Schedule B (Form 990,990-EZ, or 990-PF) (2019) 1 2 Page 2 Name of organization - - Employer identification number Asian Pacific American i'arf l Contributors (see instructions). Use duplicate copies of Part I if additional space is needed. No Name,address,and ZIP+4 Total Type of contribution contributions 1 AT&T Person ❑X ---------------- Payroll ❑ _____$_____ 50,000_ Noncash ❑ San Francisco CA 94105 (Complete Part 11 for — —— ——__ noncash contributions.) No Name,address,and ZIP+4 Total Type of contribution contributions 2 Civic Leadership [ISA Person - ---------- Payroll $ 5,000_ Noncash ❑ San Mateo, CA 94401 (Complete Part 11 for _—— — ______ noncash contributions.) Noa b c . Name,address,and ZIP+4 Total Type of contribution contributions Person 3 Glenn. Osaka ' --- 7-------------------------------------------------------------- Payroll 5,000. Noncash ❑ San Jose CA 95125 . (Complete Part II for -----'----------•--------------------- noncash contributions.) Noa b c . Name,address,and ZIP+4 Total Type of contribution contributions Person Payroll ❑ —__—__— _---_______ $___ 20,000. Noncash ❑ Los Altos Hills, CA 94022 (Complete Part II for ___________________ noncash contributions.) Noa b d . Name,address,and ZIP+4 Total Type of contribution contributions 5 PG&F Person ❑X Payroll ❑ —_._-- —_--_.—_..�------------^�------- 7,500. Noncash ❑ San Francisco, CA 94177 (Complete Part 11 for —_— —_ noncash contributions.) Noa 6 Name,address,and ZIP+4 Tot I Type of contribution contributions 6__ Silicon Valley Communi� Foundation_____ ------ Person ❑X _ �r--M—�—� --- ---- Payroll ❑ +—____ 90,000_ Noncash ❑ 1�ojujinjjt�ain View, CA 94040 (Complete Part 11 for ---------------------------------- noncash contributions.) BAA TEEA0702L OW09119 Schedule B(Form 990,990-EZ,or 990-PF)(2019) Schedule B (Form 990, 990•EZ, or 990-PF) (2019) 2 2 Page 2 Name of organization Employer IdeRWICatl0h number Asian Pacific American Part l: Contributors (see instructions). Use duplicate copies of Part I if additional space is needed. No Name,address,and ZIP+4 Total Type of contribution contributions 7 Southwest Airlines Person ------------ Payroll ❑ 12,383_ Noncash ❑ Isana Jose CA 95113 (Complete Part II for __________________ noncashcontributions,) bd No Name,address,and ZIP+4 Total Type of contribution contributions 8__ Kaiser Permanente_____ Person ----------_---.._�._..�-�_ Payroll -_-_-$____-_ 5---- Noncash ❑ Cu ertino, CA 95014 (Complete Part 11 for P-tk- ----------------------- .- noncashcontrihutions.) Noa b c d . Name,address,and ZIP+4 Total Type of contribution contributions i I i Person 9-- Tianc�iao &_Chrissy_Chen Institute ____________ ❑ - -- --- ------- Payroll $ _---100,000_ Noncash ❑ Menlo Park CA 94025 (Complete Part Il for - - - - - - - - - .--.-..-..------------------ noncashcontributions.) Noa b c . Name,address,and ZIP+4 Total Type of contribution contributions Person ❑ i --- ------------------------- ---------- Payroll ❑ ----------------------------- ---- - $ __- Noncash ❑ (Complete Part 11 for j ______________________ ______________ noncashcontributions.) i Noa b . Name,address,and ZIP+4 Total Type of contribution { contributions Person ❑ --- -----------------------------._._-_---- Payroll ❑ -----------------------------� _� -wn $ �- _ .- Noncash ❑ (Complete Part II for (( _______-__-_..--- noncash contributions.) No Name,address,and ZIP+4 Tot)af Type of contribution contributions Person ❑ Payroll ❑ $ -- Noncash ❑ (Complete Part 11 for --.-----___-.--------_- -_____ noncashcontributions.) BAA TEEao702L 03109119 Schedule B(Form 990,990-EZ,or 990-PF)(2019) Schedule B (Form 990, 990-EZ,or 990-PF) (2019) 1 1 Page 3 Hame of organization Employer Identification number Asian Pacific American Part II Norica§h Property(see instructions). Use duplicate copies of Part JI if additional space is needed. a No. b d (from Description of noncash property given FMV(or estimate) Date received Part I (See instructions.) N/A .----------------------------------------- a No. b c (from Description of noncash property given FMV(or estimate) Date received Part I (See instructions.) ------------------------------------------ ---- ------------------------------------._.__._,_- --------------------------....._._.-._-----_..-_.- (a)No. (b) (c) (d) from Description of noncash property given FMV.(or estimate) Date received Part I (See instructions.) ----------------------------------------- (a)No. Is from Description of noncash property given FMV(or(estimate) Date redceived Part I (See instructions.) ------------------------------------------ -------._............_ --------._..._--._.._..._........._.-__...------- (a)No. b c dc from Description of noncash property given FMV(or estimate) Date reeived Part I (See instructions.) ------------------------------------------ - i j i -------------------------------------- -------------------------------.....------ -- -------------------_ E a No. b c dI (from Description of noncash property given FMV(or estimate) Date received Part I (See instructions.) ------------------------------------------- ---- ------------------------------------------ ----------------------------------------- ------------------------------------------ -------------------- BAA Schedule B(Form 990,990-EZ,or 990-PF)(2019) TEEA0703L 0B109119 Schedule B (Form 990, 990-EZ,or 990-PF) (2019) 1 1 Page 4 Name of organization I Employer identification number Asian Pacific American Part llf Exclusively religious,charitable, etc., contributions to organizations described in section 501(c)(7),(8), or(10)that total more than $1,000 for the year from any one contributor.complete columns(a)through(a)and the following line entry. For organizations completing Part II[, enter the total of exclusively religious, charitable, etc., contributions of$1,000 or less for the year. (Enter this information once, See instructions.)............ ' $ Use duplicate copies of Part III if additional space is.needed. a b c No. Purpose of gift Use of gift Description of how gift is held Part I N/A (e) Transfer of gift Transferee's name,address,and ZIP+4 Relationship of transferor to transferee ----------------------------------- ---------------------------- ----------------------------------- ------------------------------ a b c No. Purpose of gift Use of gift Description of how gift is held Part I --------------------- ._......---------- -- -------------------- ------------------- —--------------- e Transfer of gift Transferee's name,address,and ZIP+4 Relationship of transferor to transferee ---------------------------------------------------------------- a b No.from Purpose of gift Use of gift Description of how gift is held Part 3 -.-..---..-..- —..-..-•--------" (e) Transfer of gift Transferee's name,address,and ZIP+4 Relationship of transferor to transferee ------------------------------------------------------------------ ---------------------------------- ----------------- ------- ---------------------------------------------------------------- a b c No. Purpose of gift Use of gift Description of how gift is held Part ---------------------------------------------------------------- (e) Transfer of gift Transferee's name,address,and ZIP+4 Relationship of'transferor to transferee ---------------------------------------------------------------- ---------------------------------------------------------------- ----------------------------------- ---------------------------- BAA Schedule B(Form 990,990-EZ,or 990-PF)(2019) TEEA0704L 08109/19 ' B No,1545-0047 SCHEDULE D Supplemental Financial Statements OMB (Form 990) • Complete if the organization answered'Yes'on Form 990, Part IV,line 6,7,8,9,10,11a,11 b,11c,1ld,Ile,11f,12a,or 12b. ► Attach to Form 990. Q eri to'Nublic ❑epartment of the Treasury • Go to www.frs.gov7Form990 for instructions and the latest information. p Internal Revenue Service ,inspection Name of the organization Employer identification number Asian Pacific American Leadership Institute part t".': Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered 'Yes' on Form 990, Part [V, line 6. (a)Donor advised funds (b)Funds and other accounts 1 Total number at end of year....I........ . 2 aggregate value of contributions to(during year)....... 3 aggregate value of grants from(during year)......... 4 Aggregate value at end of year.............. 5 Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization's property, subject to the organization's exclusive legal control?........................... Yes F]No 6 Did the orgganization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitahle purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit?............................ ........ 0 Yes No Part ll:r-':I Conservation Easements. Complete if the organization answered 'Yes' on Form 990, Part IV, line 7, 1 Purpose(s)of conservation easements held by the organization (check all that apply). Preservation of land for public use(for example,recreation or education) H .Preservation of a historically important land area Protection of natural habitat Preservation of a certified historic structure ' Preservation of open space 2 Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year, Held at the End of the Tax Year a Total number of conservation easements.................................................... 2a bTotal acreage restricted by conservation easements,.... ...................... asements............................... 2b c Number of conservation easements on a certified historic structure included in (a)............. 2c d Number of conservation easements included in (c) acquired after 7125/06,and not on.a historic structure listed in the National Register............................................... .......I 2d 3 Number of conservation easements modified,transferred,released, extinguished,or terminated by the organization during the tax year ► 4 Number of states where property subject to conservation easement is located ► 5 Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds?.................................................... P Yes. No 6 Staff and volunteer hours devoted to monitoring,inspecting,handling of violations, and enforcing conservation easements during the year I ► l 7 Amount of expenses incurred in monitoring, inspecting, handling of violations,and enforcing conservation easements during the year ►$ 8 Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) i and section 170(h)(4)(13)(4)?............................................ ....I...I Yes No 9 In Part X1II, describe how the organization reports conservation easements in its.revenue and expense.statomont and balance sheet, and include, if applicable, the text of the footnote to the organization's financial statements that describes the organization's accounting for conservation easements. Part"lll Organizations Maintaining Collections of Art, Historical Treasures,or Other Similar Assets. Complete if the organization answered 'Yes' on Form 990, Part IV, line 8. 1 a If the organization elected,,as permitted under FASB ASC 958, not to report in its revenue statement and balance sheet works of art, historical treasures,or other similar assets held for public exhibition, education, or research in furtherance of public service, provide in Part XI11 the text of the footnote to its"financial statements that describes these items. b If the organization elected,as permitted under FASB ASC 958, to report in its revenue statement and balance sheet works of art, historical treasures,or other similar assets held for public exhibition,education,or research in furtherance of public service,provide the following amounts relating to these items: (1) Revenue included on Form 990, Part Vill, line 1........................................................ $ (ii) Assets included in Form 990, Part X................................................................... $ 2 If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the following amounts required to be reported under FASB ASC 958 relating to these items: a Revenue included on Form 990, Part VIII, line 1............................................................. •$ b Assets included in Form 990, Part X...................................................................... •$ BAA For Paperwork Reduction Act Notice,see the Instructions for Form 990. TEEA3301L 8f22119 Schedule D(Form 990)2019 Schedule D (Form 990)2019 Asian Pacific American Page 2 Part Ilk Organizations Maintaining Collections of Art, Historical Treasures,or Other Similar Assets (continued) 3 Using the organization's acquisition,accession,and other records,.check any of the following that make significant use of its collection items (check all that apply): a Public exhibition d Loan or exchange program b Scholarly research e ❑Other c Preservation for future generations 4 Provide a description of the organization's collections and explain how they further the organization's exempt purpose in Part XIII. 5 During the year, did the organization solicit or receive donations of art, historical treasures, or other similar assets to be sold to raise funds rather than to be maintained as part of the organization's collection?.................... ❑Yes ❑No J.Paft IV;I Escrow and Custodial Arrangements. Complete if the organization answered 'Yes' on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X,-line 21. 1 a Is the organization an agent, trustee,.custodian or other intermediary for contributions or other assets not included on Form 990, Part X?........................ []Yes ❑No 4 If'Yes,'explain the arrangement in Part XIII and complete the following table: Amount c Beginning balance......................................................................... 1 c d Additions during the year................................................................... 1 d e Distributions during the year................................................................ 1 e fEnding balance................................................................ .. 1f 2a Did the organization include an amount on Form 990, Part X, line 21,for escrow or custodial account liability?..... ❑Yes No b If'Yes,' explain the arrangement in Part XIII. Check here if the explanation has been provided on Part XIII..................... Part V�,I Endowment Funds. Complete if the or anization answered 'Yes' on Form 990 Part IV line 10. (a)Current year (b)Prior year (c)Two years back (d)Three years back (e)Four years back — 1 a Beginning of year balance....... _ b Contributions.. c Net investment earnings, gains, and losses.................... d Grants or scholarships...,..... e Other expenditures for facilities and programs................ f Administrative expenses....... g End of year balance..:........ •2 Provide the estimated percentage of the current year end balance (line lg, column (a)) held as: a Board designated or quasi endowment o % b Permanent endowment o c Term endowment _P� o The percentages on lines 2a,2b, and 2c should equal 100%. 3a Are there endowment funds not in the possession of the organization that are held and administered for the organization by: Yes No (i) Unrelated organizations.................................................................................... 3a(i) (ii) Related organizations.................................................................. ............. 3a(II) b If'Yes' on line 3a(ii), are the related organizations listed as required on Schedule R?............................... 3b 4 Describe in Part XIII the intended uses of the organization's endowment funds. Pad.`A Land, Buildings,and Equipment. Complete'if the organization answered 'Yes' on Form 990, Part IV, line 11 a. See Form 990, Part X, line 10. Description of property (a)Cost or other basis (b)Cost or other (c)Accumulated (d)Book value (investment) basis (other) depreciation 1 a Land...................................... b Buildings.................................. c Leasehold improvements................... d Equipment................................ eOther..................................... Total.Add lines 1 a through le. (Column(d)must equal Form 990, Fart X, column (B), tine 10c.)..................... ► 0. . RAA Schedule b(Form 990)2019 TEEA3302L 8122119 Schedule D (Form 990)2019 Asian Pacific American Page 3 Part>Vil Investments— Other Securities.. N/A Complete if the organization answerer[ 'Yes'.on Form 990, Part IV, line 11 b. See Form 990 Part X, line 12. (a)Description of security or category(including name of security) (b)Book value (c)Method of valuation:Cost or end-of-year market value (1) Financial derivatives................................ (2) Closely held equity interests,........................ (3) Other (A) ---------------------------- (B) (D) ---------------------------- (E) (F) (G) (H) ----------------------- Total.(Column(b)must equal Farm 990,Part X,column(B)line 12.). Part:Vlll. Investments —Program Related. N/A Complete if the organization answered 'Yes' on Form 990, Part IV, line 11 c. See Form 990, Part X, line 13. (a)Description of investment (b)Book value (c)Method of valuation:Cost or end-of-year market value (1) (2) (3) 4) (5) (6) (7) 1 (3) (9) (10) Total. Column b must equal Form 990 Part column B line 13. .. Part IX ' Other Assets. N/A Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15. (a)Description (b)Book value (1) (2) (3) (4) j (5) i (6) (7) (9) (10) Total. (Column (b)must equal Form 990, Part X, column (B)line 15.).............................................. P O X'`:' Other Liabilities. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 1 tf.See Form 990, Part X, line 25. 1. (a)Description of liability (b)Book value (1) Federal income taxes (2) Payro7l liabilities 3,778. (3) (4) (5) (6) (7) (8) (9) 0 0) (11) Total.(Column(b)must equal Farm 990,Part X,column(B)line 25.)............................................................. 0-1 3,778. 2.Liability for uncortain tax positions.In Part XIII,provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FASB ASC 740,Check here if the text of the footnote has been provided in.Part XIII........................................................ BAA TEEA3303L 8122119 schedule 6?Form 990TWI9 Schedule D(Form 990) 2019 Asian Pacific American Page 4 RXV Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. N/A Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a. 1 Total revenue,gains, and other support per audited financial statements.................................. 1 2 Amounts included on line 1 but not on Form 990, Part VIII, line 12: a Net unrealized gains(losses) on investments.................. ..... 2a b Donated services and use of facilities.....................................:.. 2 b c Recoveries of prior year grants.............................................. 2 c d Other(Describe in Part XIII.)............ e Add lines 2a through 2d.................................. ............................................. 2 e 3 Subtract line 2e from line 1............................................................................. 3 4 Amounts included on Form 990,Part VIII, line 12, but not on line 1: a Investment expenses not included on Form 990, Part VIII, line 7b.............. 4a b Other(Describe in Part XIII.)................................................ 4 b c Add lines 4a and 4b................................................................................ 4 c 5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part 1, line 72.)............. ... 5 Part Xll': Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. N/A Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a. 1 Total expenses and losses per audited financial statements........................ .... ............. 1 2 Amounts included on line 1 but not on Form 990, Part IX, line 25: 1 a Donated services and use of facilities........................................ 2a 1 b Prior year adjustments...................... .................. 2 b c Otherlosses.............. ....... 2 c d Other(Describe in Part X111.)................................................ 2 d e Add lines 2a through 2d................................................................................. 2 e 3- Subtract line 2efrom line 1...............................................:............................. 3 4 Amounts included on Form 990, Part IX, line 25, but not on line 1: a Investment expenses not included on Form 990, Part Vlll, line 7b.............. 4 a ; b Other(Describe in Part X111.)................................................ 4 b c Add lines 4a and 4b................................................................................... 4c 5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part 1,dine 18.)........................... 5 p6etal'I Supplemental Information. Provide the descriptions required for Part 11, lines 3, 5, and 9; Part III, lines I and 4; Part.IV, lines I and 2b; Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information. I I I BAA Schedule D(Form 990)2019 TEEA3304L a122119 SCHEDULE O Supplemental Information to Form 990 or 9.90-EZ OMB No.1545.O 41 (Form 990 or 990-EZ) Complete to provide information for responses to specific questions on 2Q"RR� Form 990 or 990-EZ or to provide any additional information. m Attach to Form 990 or 990-EZ. Department of the Treasury d Go to wwwJrs.gov/Form990 for the latest information. Open to Public ' Internal Revenue Service ::_Inspection Name of the organization Asian Pacific American. Employer identification number Leadership Institute Form 990,Part V1, Line 11 b-Form 990 Review Process Review conducted as .part of scheduled Board meeting. Form 990, Part VI, Line 1Sa-Compensation Review&Approval.Process- CEO&Top Management No applicable roles exist fo so process was necessary. Form 990,Part VI, Line 15b-Compensation Review&Approval Process-Officers&Key Employees No applicable roles exist fo so process was necessary. Form 990,Part VI, Line 19-Other Organization Documents Publicly Available Documents are available upon request. BAA For Paperwork Reduction Act Notice,see the Instructions for Form 990 or 990-EZ. TEEA4901 L 08/19/19 Schedule 0(Form 990 or 990-EZ)(2019) TAXABLE.YEAR California Exempt Organization FORM 2019 Annual Information Return 199 Calendar Year 2019 or fiscal year beginning(mmlddlyyyy) and ending(mmlddlyyyy) Corporation rgamzahon name ASIAN PACIFIC AMERICAN California corporation number ,LEADERSHIP INSTITUTE Additional information.See instructions. FEIN Street address suite or room �� PMB no. State Zip code CUPERTINO CA 95014 Foreign country name Foreign provincerstatelcounty Foreign postal code A First Return....................... .... ❑Yes X❑No J If exempt under R&TC Section 23701d,has the B Amended Return.................................. • H Yes NX No organization engaged in political activities? C IRC Section 4947(a)(1)trust........................... Yes No See instructions. • ❑Yes 9 No D Final information Return?- • ❑Dissolved ❑surrendered(Withdrawn) ❑Merged/Reorganized K Is the organization exempt undei R&TC Section 237Qtg?... • Des 0 No mm/dd/ • if"Yes,"enter the gross receipts from Enter date: ( YYYY) nonmember sources..................... $ E Check accounting method: L If organization is a public charity exempt under 1 X❑Cash 2 ❑Accrual 3 ❑Other R&TC Section 23701d and meets the filing fee F Federal return filed? 1 • ❑990T 2 • ❑990-PF 3• ❑SO H(990) exception,check box.No filing fee is required.......... • ❑ 4❑Other 990 series M Is the organization a Limited Liability Company?......... • ❑Yes ❑X No G Is this a group filing?See instructions.................. • ❑Yes ❑X No N Did the organization file Form 100 or Form 109 to report taxable income?................................ • ❑Yes 0 No H Is this organization in a group exemption.................. El Yes 0 No D Is the organization under audit by the IRS or has the IRS If"Yes,"what is the parent's name? audited in a prior year?........................... • ❑Yes 0 No P Is federal Form 1023/1024 pending?................... ❑Yes ❑No Did the organization have any changes to its guidelines Date filed with IRS not reported to the FIB?See instructions................ • ❑Yes No j Part l Complete Part I unless not.required to file this form.See General Information B and C. 1 Gross sales or receipts from other sources. From Side 2, Part II, line 8..................... • 1 _ 5,528. 2 Gross dues and assessments from members and affiliates.. ........................... • 2 Receipt ands 3 Gross contributions, gifts, grants, and similar amounts received............SEE..801...B. • 3 346 145. I Revenues 4. Total gross receipts for filing requirement test. Add line 1 through line 3. `,.i This line must be completed. If the result is less than$50,000,see General Information B.. • 4 351 673. 5 Cost of goods sold......................................... • 5 c i 6 Cost or other basis, and sales expenses of assets sold....... • 6 7 Total costs. Add line 5 and line 6......................................................... 7 8 Total gross income.Subtract line 7 from line 4............................................ • 8 351 673. Expenses 9 . Total expenses and disbursements. From Side 2, Part ll, line 18........................... • 9 181 368. 10 Excess of receipts over expenses and disbursements. Subtract Line 9 from line 8........... • 10 174 305. 11 Total payments......................................................................... • 11 12 Use tax. See General Information K........................ 0 12 13 Payments balance. If line 11 is more than line 12, subtract line 12 from line 11 ............. • 13 Filing 14 Use tax balance. If line 12 is more than line 11,subtract line 11 from line 12................ • 14 Fee 15 Filing fee $10 or$25. See General Information F............................................ 15 10. 16 Penalties and Interest, See General Information J........................................... 16 17 Balance due.Add line 12 line 15 and line 16.Then subtract line 11 from the result........... .............(�) 17 10. Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,it is true, Sign correct,and complete.Declaration of preparer(other than taxpayer)is based on all information of which preparer has any knowledge. Here Signature ' Title Date 0 Telephone of officer EXECUTIVE DIRECTOR Date_ Check if • PTIN t'reparer's self- Paid signature employed Preparer's • Firm`s FEIN Use OnlyFirm's name (oryoum if Sol F'em toyed) - and address • Telephone May the FTB discuss this return with the preparer shown above? See instructions.................... • X YesLjNo CACA1112L 12113/19 �� r Form 199 2019 Pagel ASIAN PACIFIC AMERICAN Part II Organizations with gross receipts of more than$50,000 and private foundations regardless of amount of gross receipts—complete Part II or furnish substitute information. 1 Gross sales or receipts from all business activities. See instructions......................:.. • 1 2 Interest................................................................................. • 2 179. Receipts3 Dividends.................................... ............................... • 3 from4 Gross rents.............................................................................. • 4. Other 5 Gross royalties......... ...... • 5 Sources ....................................................... 6 Gross amount received from sale of assets (See Instructions)............................... • 6 7 Other income.Attach schedule...................................SEE„STATEMENT.1. • 7 5,349. 8 Total gross sales or receipts from other sources.Add line 1 through line 7.Enter here and on Page 1,Part I,line 1...... 8 5,528. 9 Contributions,gifts,grants,and similar amounts paid.Attach schedule..................................... • 9 10 Disbursements to or for members......................................................... • 10 11 Compensation of officers,directors, and trustees. Attach schedule..........SEE STNlT 2 • 11 40,002. 12 Other salaries and wages................................................................. • 12 77,094. Expenses 13 Interest........... and • 73 Disburse- 14 Taxes..................................... .. ..............................I........... .• 14 9,809. ments 15 Rents.............. -- 16 Depreciation and depletion (See instructions).............................................. • 16 17 Other Expenses and Disbursements.Attach schedule.............. SEE,.$TATEMEN'>'-3 • 1.7 54,463. 18 Total expenses and disbursements.Add line 9 through line 17.Enter here and on Page 1,Part I,line 9............... 18 181,368. Schedule L Balance Sheet Beginning of taxable year End of taxable year Assets (a) (b) (c) (d) 1 Cash........:............................ 321 522. ;::' . '.; • 493 948. 2 Net accounts receivable.............. • 3 Net notes receivable........................ • 4 Inventories............... :::•. 5 Federal and state government obligations...,..... • 6 Investments in other bonds • 7 Investments in stock. • 8 Mortgage loans............................. • 9 Other investments.Attach schedule.............. . " • 10a Depreciable assets........................... 1 b Less accumulated depreciation.................. _ 1 11 Land................. .................. • i 12 Other assets.Attach schedule......:......... 13 Total assets............................... " 321,522. 493 948. Liabilities and net worth 14 Accounts payable............................ • 15 Contributions,gifts,or grants payable............ • 16 Bonds and notes payable..................... • 17 Mortgages payable........................... 18 Other liabilities.Attach schedule.........,STM 4 1,657. 3,778. 19 Capital stock or principal fund.................. • 20 Paid-in or capital surplus.Attach reconciliation...... • 21 Retained earnings or income fund............... " 319,865. • 490,11.70. 22 Total liabilities and net worth................ " 321 522. 493 948. Schedule M-1 Reconciliation of income per books with income per return Do not complete this schedule if the amount on Schedule L, line 13,column(d), is less than$50,000 1 Net income per books....................... • 170,305. 7 Income recorded on books this year not.included 2 Federal income tax.......................... • in this return.Attach schedule............ • 3 Excess of capital lasses over capital gains........ • 8 Deductions in this return not charged 4 Income not recorded on boots this year. against book income this year. Attach schedule ....................... • Attach schedule....................... • 5 Expenses recorded on books this year not deducted 9 Total.Add line 7 and line a.............. in this return.Attach schedule................. • 10 Net income per return. 6 Total.Add line 1 through"line 5................. 170 305. Subtract line 9 from line 6.......... 170 305 Page 2 Form 199 2019 � CACA1112L tti13n9 Schedule B California Copy OMB No.1545-0047 (Form 990,990-EZ, Schedule of Contributors or 990-PF) ► Attach to Form 990,Form 990-EZ,or Form 990-PF. 2019 Department of the Treasury Internal Revenue Service ► Go to wwwJrs.gov/Porm990 for the latest information. Name of the organizationAsian Pacific American Employer Identification number Leadership Institute Organization type(check one): Filers of: Section: Form 990 or 990-EZ 501(c)( 3 ) (enter number)organization 4947(a)(1) nonexempt charitable trust not treated as a private foundation Form 990-PF ❑ 527 political organization 501(c)(3)exempt private foundation ❑ 4947(a)(1) nonexempt charitable-trust treated as a private foundation. { ❑ 501(c)(3) taxable private foundation Check if your organization is covered by the General Rule or a Special Rule. Note:Only a section 501(c)(7), (S), or(10) organization can check boxes for both the General Rule and a Special Rule. See instructions. General Rule 0 For an organization filing Form 990,990-EZ,or 990-PF that received,during the year,contributions totaling$5,000 or more(in money or property)from any one contributor.Complete Parts I and ll.See instructions for determining a contributor's total contributions. Special Rules For an organization described in section 501(c)(3)filing Form 990 or 990-EZ that met the 33-1/3%support test of the regulations under sections 509(a)(1)and 170(b)(1)(A)(vi),that checked Schedule A(Form 990 or 990-EZ),Part Il,line 13, 16a,or 16b,and that received from any one contributor, during the year, total contributions of the greater of(1) $5,000; or(2)2%of the amount on (i) Form 990, Part Vill, line 1h; or(ii)Form 990-EZ, line 1, Complete Parts I and ll. ❑ For an organization described in section 501(c)(7), (S), or(10)filing Form 990 or 990-EZ that received from any one contributor, during the year, total contributions of more than $1,000 exclusivelyfor religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III. ❑ For an organization described in section 501(c)(7), (S), or(10)filing Form 990 or 990-EZ that received from any one contributor, during the year, contributions exclusively for religious, charitable, etc„ purposes, but no such contributions totaled more than $1,000. if this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Don't complete any of the parts unless the General Rule applies to this organization because. it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year. P�$ Caution:An organization'that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B (Form 990, 990-EZ, or 990-PF), but it must answer'No'on Part IV, line 2,of its Form 990; or check the box on line H of its Form 990-EZ or on its Form 990-PF, Part I, line 2, to certify that it doesn't meet the filing requirements of Schedule B (Form 990,990-EZ,or 990-PF). BAA For Paperwork Reduction Act Notice,see the instructions for Form 990,990-EZ,or 990-PF. Schedule B(Form 990,990-EZ,or 990-PF)(2019} TEEA0701L 0Bl09119 Schedule B (Form'990, 990-EZ,or 990-PF) (2019) 1 2 Page 2 Name of organization Employer identiflcatlon number Asian Pacific American Part*-I Contributors(see instructions). Use duplicate copies of Part I if additional space is needed. bd No Name,address,and ZIP+4 Total Type of contribution contributions 1 AT&T Person -- - _ _---------_— _--- ------------- Payroll ❑ ---------------$_____ 50,000_ Noncash ❑ 7R 'ncisco CA 94105 (Complete Part II for ----------------- .———— -----_ noncash contributions.) No Name,address,and ZIP+4 Total Type of contribution contributions - Person 2 Civic Leadersh i1D USA _________________ Payroll ❑ _—$_---^— 5,000_ Noncash ❑ San Mateo, CA 94401 (Complete Part II for ------------------ .-.--------------- —.-.— noncash contributions.) (a) (b) (c) (d) No. Name,address,and ZIP+4 Total Type of contribution contributions . 3 Glenn Osaka Person ❑X --_ —————————---————————————— —————— Payroll $------ 5L000_ Noncash ❑ San Jose, CA 95125 (Complete Part II for ------------------------------------- noncash contributions.) (a) (b) (c) (d) No. Name,address,and ZIP+4 Total Type of contribution contributions 4 Hsin Kun Person --- --n---g-------=------------ - --_ —-——— Payroll ❑ _-------_ ----- $—µ--- 20�000 Noncash ❑ Los Altos—Hills,— CA 94022 (Complete Part II for _. ------------------------ ---------- noncash contributions.) (a) (b) (c) (d) I No. Name,address,and ZIP+4 Total Type of contribution 1 contributions I 5 PG&E Person ❑X --- ---------------------------------- Payroll ❑ ---------------------_ ——— $._----- 7,500. Noncash ❑ (Complete Part II for San Francisco,_CA 94177 -------------------- noncash contributions.) No Name,address,and ZIP+4 Total Type of contribution contributions 6 Silicon ValleyCommuni Foundation------ Person — --------- --- ----- ----- Payroll ❑ $ ___ 90,000. Noncash ❑ Mountain View; CA 94040 — noncash contributions.) BAA TEEA0702L 0er09119 Schedule B(Form 990;990-EZ,or990-PF)(2019) Schedule B(Form 990, 990-EZ, or 990-PF) (2019) 2 2 Page 2 Name of organization Employer Identification number Asian Pacific American Pa((lf'I Contributors(see instructions). Use duplicate copies of Part I if additional space is needed. No. Name,address,and ZIP+4 Total Type of'contribution contributions 7 Southwest Airlines Person ❑ ------------- Payroll 121383_ Noncash ❑ ———__— — (Complete Part 11 for r§annse —CA 95113 —————— noncash contributions.) No Name,address,and ZIP+4 Tot 1 Type of contribution contributions 8 Kaiser Permanente Person ❑ --- ------------_.._._��._._------------------ Payroll ❑. ------ ------ ---- Noncash ❑ Cu ertino CA 95014 (Complete Part It for _ _ __,————————— —— ———— noncash contributions.) Noa b c d . Name,address,and ZIP+4 Total Type of contribution contributions 9__ Tian�ao & Chrissy Chen Institute _____—_^-- Person -- ---- — -------.— Payroll ❑ $ 100 000. Noncash ❑ Menlo.Park, CA 94025 (Complete Part 11 for ------------------------------------ noncash contributions.) (a) (b) (c) (d) No. Name,address,and ZIP+4 Total Type of contribution contributions Person ❑ Payroll $ _ Noncash ❑ j 1 (Complete Part II for .__—.._.T._.—_____________________________ noncash contributions.) � I (a) (b) (c) (d) I No. Name,address,and ZIP+4 Total Type of contribution I contributions i Person ❑ ___ —_..__--__._._—_--------------------- ——— Payroll I ❑ ! Noncash ❑ (Complete Part II for (( __—_ _—_—_____ noncash contributions.) No Name,address,and ZIP+4 Total Type of contribution contributions Person ❑ _ — --..----------------------------- Payroll ❑ Noncash ❑ (Complete Part 11 for __________________ noncash contributions.) BA A TEEA07o2L oW9119 Schedule B(Form 990,990-EZ,or 990-PF)(2019) Schedule 8 (Form 990, 990-EZ, or 990-PF) (2019) 1 Page 3 Name of organization Employer identification number Asian Pacific ,American Noncash Property(see instructions). Use duplicate copies of Part II if additional space is needed. a No. b c d (from Description of noncash property given FMV(or estimate) Date received Part I (See instructions.) N/A _. -_..- -..,.....-_..------ ...... --.---------------=-- -_-.-......._.._----------.----------------------- $---------------- --- a No. b c (from Description of noncash property given FMV(or estimate) Date received Part I (See instructions.) ------------------------------------------- ---- ---------------------------------.._._._._-__- - ------------------------------------------ -------------------- (a)No. (b) (c) (d) from Description of noncash property given FMV(or estimate) Date received Part I See instructions.)( .- --------------- ..- .-------- ---w --- ------------------------ - --- - .------------------------ $ -------------------------- a No. b (from Description of noncash property given FMV(or estimate) Date received Part I (See instructions.) --------------------------------_.-- - .... — ---------------------------.._.._------------ ----------------------------------•----------- $-------------------- (a)No. (b) (c) (d) 1 from Description of noncash property given FMV(or estimate) Date received Part I (See instructions.) ------------------------------------------ ---- ------------------------------------------ ---------------------------------------- $ i -------------------------------- --_.___- ------ ---------------------- (a)No. b from Description of noncash property given FMV(or estimate) Date received Part I (See instructions.) ------------------------------------------ ---- ---------------------------------------- ------------------------------------------ BAA Schedule B(Form 990,990-EZ,or 990-PF)(2019) TEEA0703L 0810911.9 Schedule B (Form 990,990-EZ,or 990-PF) (2019) 1 Page 4 Name of organization LEmMover.1&ntification number Asian Pacific American Part:`III. Exclusively religious;charitable,etc., contributions to organizations described in section 501(c)(7),(8), or(10)that total more than$1,000 for the year from any one contributor.Complete columns(a)through(e)and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions.of$1,000 or less for the year, (Enter this information once. See instructions.)............ $---------RZA Use duplicate copies of Part Ili if additional space is needed. a b c fd No.fr se from Purpose of gift Use of gift Description of how gift is held Part I N/A ——.-------------------- -------------------- ————————————————————- e Transfer of gift Transferee's name,address,and ZIP+4 Relationship of transferor to transferee --------------------------------------------------------------- ---------------------------------------------------------------- _- ----_ -- ----------------------------- ------------------------ ; a b c [d No.from Purpose of gift Use of gift Description of how gift is held Part -------------=----- -------- e Transfer of gift Transferee's name,address,and ZIP+4 Relationship of transferor to transferee "..-..-...----._...".- -.._....---- --------------- -----------=--------------- Naa b c) (d from Purpose {of gift Use of gift Description of how gift is held Part -------------------- ------------------------ -------------------- --------------------- -------------------- -------- ------------------- j e Transfer of gift Transferee's name,address,and ZIP+4 Relationship of transferor to transferee ----------------------------------- ---------------------------- ----------------------------------- ---------------------------- ------------------------- ..."........... - ----------------------------- (a) � i b c fd No.frm Purpose of gift Use ofgift Description of how gift is held Part I ------------------- -------------------- -------------_._... ----- e Transfer of gift Transferee's name,address,and ZIP+4 Relationship of transferor to transferee ---------------------------------- --------------------------- ----------------------------------- BAA Schedule B(Form 990,990-EZ,or 990•PF)(2019) TEEA0704L 08109/19 - 2019 California Statements Page 1 Asian Pacific American Leadership Institute Statement 1 Form 199, Part II, Line 7 Other Income Program Service Revenue....................................................................... $ 5,349. Total $ 5,349. Statement 2 Form 199, Part II, Line 11 Compensation of Officers, Directors,Trustees and Key Employees Current Officers; Title and Total Contri-- Expense Average Hours Compen- bution to Account/ Name and Address Per Week Devoted sation EBP & DC Other Michael Chang Executive Dir. $ 40,002. $ 0. .$ 0. 10.00 i Glenn Osaka Treasurer 0. 0. 0. 1.00 i Paul Fong Secretary 0. 0. 0. 1.00 I Total $ 40,002. $ 0. 0. i I i i . i Statement 3 Form 199, Part II, Line 17 Other Expenses Advertising and Promotion..................................................................... $ 4,428. Gala................... ............................................................................. 17,310. Insurance............................................................................... 4,100. LegalFees............................................................................................. 3,260. OfficeExpenses..................................................... ............................... 8,372. Program................................................................. 16,839. Travel.................................................................................................. 154. Total $ 54,463. Statement 4 Form 199,Schedule L, Line 18 Other Liabilities Payroll liabilities........................................ 3,778. Total $ 3,778. APALI Asian Pacific American Leadership Institute REVENUE & EXPENSES January-December 2020 TOTAL Revenue Non-Profit Revenue Direct Contributions Corporate/Other Public Contributions 116,800.01 Individual Direct Contributions 21,908.80 Total Direct Contributions 138,708.81 Gala 5,000.00 Grants Corporate Grants 2,000.00 Total Grants 2,000.00 Total Ikon-Profit Revenue 1.45,708.81 Program Fee/Revenuo/Income 2,024.18 Total Revenue $147,732.99 GROSS PROFIT $147732.99 Expenditures j i Bank Charges&Fees 13.20 j Business Meetings-Meals 572.30 Fund Development Expense 479.88 Gala/Benefit Expenses 222.16 Insurance 4,101.32 Legal&Professional Services 4,052.50 Office Supplies&Software 505.11 i Office/General Administrative Expenditures 510.00 Online services 2,764.12 Other Business Expenses 150.00 . Payroll Expenses Taxes 12,969.32 Wages 154,935.80 Total Payroll Expenses . 167,9135.12 Program Expenses 4,885.67 Taxes&Licenses 85.00 Total Expenditures $186,246.38 NET OPERATING REVENUE $-38,513.39 Other Revenue Interest income 255.80. Total Other Revenue $255.60 NET OTHER REVENUE $255.80 NET REVENUE $-38,257.59 Cash Basis Thursday,January 28,2021 11:02 PM GMT-08:00 9I1 i9e�°= `~"e California Secretary of State Electronic Certified Copy uroaa . I, ALEX PADILLA, Secretary of State of the State of California, hereby certify that the attached transcript of 2 pages is a full, true and correct copy of the original record in the custody of the California Secretary of State's office. IN WITNESS WHEREOF, I execute • ��;A F this certificate and affix the Great ` Seal of the State of California on 0 this day of January 11, 2021 ALEX PADILLA Secretary of State Verification Number: •' ,f Entity (File) Number: To verify the issuance of this Certificate, use the Verificat166-`N`urrib- above with the Secretary of State Electronic Verification Search available at ' bizMe.sos.ca.gov L DI California Secretary of State MEN 1] Electronic Filing Secretary of State State of California Corporation - Statement of Information Entity Name: ASIAN PACIFIC AMERICAN LEADERSHIP INSTITUTE Entity (File) Number: File Date- 0110912021 Entity Type: Corpofation Jurisdiction: CALIFORNIA - Document ld; Detailed Filing Information � 9. Entity Name: ASIAN PACIFIC AMERICAN LEADERSHIP INSTITUTE W a 2. Business Addresses: q} a. Street Address of Principal (� Office in California: m Cupertino, California 95d14 - Ql m United States of America U Z) b. Mailing Address: Cupertino, California 95014 United States of America 3. Officers: a. Chief Executive Officer: fthichael Chan Cupertino, California 95914 United States of America b. Secretary: Dennis Chiu tw Berkeley, California 94710 d) United States of America C) D Use b;zfile sos.ca,gov for online;Flings, searches, business records, and resources. Sfi�L F ryF x 4 California Secretary of State (Electronic Filing -LIFO N Officers (Cont'd): c. Chief Financial Officer: Paul Fon Sunnyvale, California 94085 United States of America 4. Agent for Service of Process: Michael Chang i - f Cupertino, California 95014 United States of America D o E V Z . U C 3y signing this document, I certify that the information is true and correct and that I am authorized by O California law to sign. V o N Electronic Signature: Michael Chang y c f ID Z N m U :D Use bizfile.sos.ca.gov for online filings, searches, business records, and resources. C U 0 Asian Pacific American Leadership Institute (APALI) (NEW) Eligibility Checklist (staff use only) Eligibility YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/projectlevent Identify how the funds will be used to benefit the Cupertino X community Be awarded only once per project X For specific needs,not on going operational costs X Have more than 75%of the requested funds allocated for direct service costs versus administrative costs X Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only NA submit one application Proceeds generated from the funded activity may only be used for NA the conducted activity admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved NA by Parks and Recreation Commission City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Community Funding Grant in the past? O Yes Q No If, Yes, when? Legal Name of Organization: Curriki Web Address: Mailing Address: City: Rpe"rfinoip: 95014 Phone: President/Executive Director: n Pin Title; Email: Telephone Number: jpinto@curriki.org Contact Person: Title: Email Address; jpirltc@curriki.org Telephone Number: SECTION 2i NON-PROFIT INFORMATION 501(c)(3)? * Yes 0 No Year Established 2006 Federal Tax IQ: Fiscal Sponsor Name- Fiscal Sponsor Address: City: Zip: Phone: SECTION 3: ORGANIZATION INFORMATION Total Organization Budget: $1,500,000 Total#of Board Members: 9 Total #of staff: 4 Total#of Volunteers: 0 Mission Statement: Build what you want the future of learning to be, At Curriki, we give anyone with an idea the technology to bring it to life, Through our free and open tools, educators can design, customize and deliver interactive learning content that will inspire the next generation of learners. Brief Description of Organization: Curriki has been a leader in open education technology for over a decade. Over the past year, we've reimagined our role in the ecosystem and launched CurrikiiStudio, which is changing the way educational experiences are designed, created, and delivered to a new generation of learners. Brief Description of Services Provided: CurrikiStudio is a free and open technology platform with turnkey tools for educators to design, customize and deliver interactive leaming content, anywhere. Curriki brings simplicity to authoring and publishing, opening up a new world of passibility for student engagement, empowering educators to create interactive experiences For learners at all levels: K-12, Higher Ed, and adult learning. Curriki partners with organizations that have quality content and learning experiences that deserve to be brought to life. Relevant examples with organizations like LA Opera, US Capitol Society, National Parks demonstrate how content can be digitized and made interactive so students in the community can engage in a new way. S;_C;l-lc)N }: t:i, k`d-r '�E0UESTS 1. Program/Project/Event Name: Bringing Cupertino Learning to Life 2. Date(s) and/or duration of program/project/event(if applicable):Fall 2021 - Spring 2022 3. Total program/prvjecUevent budget: $20.000 4. Requested Amount; $20.000 Percent of total program/project/event budget: 100% 5, Program/Project projected income: $0 Percentage of your organization's projected income: 6. Type of Request: OCapital Improvement OPmgrem Support OEvent 00ne-lime project OOther: 7.This grant will fund a(n): O Existing program/project/event;established in(year) 12 New prograelproject/event 8. Describe the purpose of requested funds and the services that will be provided: This project will empower the City of Cupertino to build mesmerizing interactive experiences using our open source authoring tool, CurikiStudic. The first step is to work closely with the City of Cupertino to identify the most valuable/loved content to engage the community. Examples include: City scavenger hunt of key landmarks with information -Volunteer training -Parks& Recreation Virtual Recreation curriculum -Tourism guide -Appoint a Learning Designer Project Manager to coordinate reviewing assets -Recruit, hire, train, and manage Cupertino School District teachers to learn about CurikiStudio to act as learning designers to make the content interactive. All content created will be WCAG accessibility compliant and mobile-friendly -We will support your technology team with cloud hosting and future updates -Design/branding to align with City guidelines 9.Please provide a line item breakdown of how the funds will be used in the categories below. If a category is not applicable, put$0: Admin Staff $1,00 MaterialwE ui ment $1.00 Entertainment $ Room[Venue Rental $ e Other Professional Services $18,00 Other $ otal $20,00 10.Explain how the request aligns to City mission and values: Currlkl s mission and that of the City of Cupertino are aligned in that both organizations are dedicated to supporting education with innovative learning tools. 11. Describe how the program/projecilevent fills a community need.Who identified this need?What other similar project/programievent exists to serve Cupertino residents? How is your proposed project/program/event unique from similar projectslprograms/events or how do you collaborate to avoid duplication? Organizations such as DoEs, nonprofits, and school districts can leverage CunikiStudio to build unique, Immersive learning experiences that engage learners in the subject matter more deeply.The tool can be used to create game- like learning, to create activities that stimulate critical thinking. It applies to any type of learning mode: remote, hybrid, in-class.We don't believe the City of Cupertino currently uses any platform to create online learning that achieves this. -Mobile-accessible to anyone -Sett-paced/selfexploration, especially in times where we can't gather to celebrate community -Engage young residents with interactive Teaming -Engage Cupertino educators in government/community curriculum -Be able to share/send links as interactive lessons on the city website 12.Who will be served by this grant? Cupertino educators Cupertino students aged K-8 Cupertino parents of kids aged K-8 a)Number of individuals total: 20,000 b)Number of Cupertino residents: 20.000 c)Particular community groups: The number of individuals and number of Cupertino residents served is dependent on the content/courses;chosen by the City to develop with CurrikiStudio.Therefore,the numbers entered above are estimates. d)Will the program/project/event be available to the entire community/public or are there any eligibility criteria? The entire community with internet connection will have access to creations. Creators that we recruitflrain/pay will need to have teaching experience and have worked in the Cupertino School District. e)Will there be a charge or fee for the programlprojectmvent(if applicable) No 1)What outreach methods does your organization use to promote the progrem/projectlevent(if applicable)? Webinar Social media Newsletter Showcase on our website Press release 13. Describe how the funds will be used to benefit or impact the Cupertino community: Providing equitable access to your quality content and making It more accessible and engaging Engage learners in interactive learning Engage Cupertino educators in this new technology that can help them deliver asynchronous blended learning. 14, Demonstrate that the member implementing and managing the program/projectlevent have adequate experience: Leonardo Cunha, CTO As Chief Technology Officer, Leo brings over 30 years of progressively challenging experience in the management, design,and development of mission-critical systems. His education technology experience spans over 15 years and includes the development and integration of systems for bath K-12 and higher education, specifically in the areas of teaming management,assessment and intervention, student information and ERP systems, and analytical processing for education. Caroline Benoist, Instructional Designer Caroline brings years of teaching, professional development, and curriculum design to her role as an instructional designer for CurrikiStudio. She has developed interactive learning experiences through CurikiStudio for K-12, higher ad, and nonprofits,trained educators, district and college leadership on building effective and remote learning experiences. Examples of Interactive learning projects created by our team: htlpsd/www.curriki.org/s 15. How will success of the programlproject/event be measured?: Cumki will report on user data to demonstrate the success of the project: #of views of projectsrplaylists/activities #of Cupertino educators using the projects in their classroom for the school year 16.Will more than 75%of the requested funds go towards direct service costs versus administrative costs? O Yes O No 17.Will you collaborate with other organizations to deliver the program/projectlevent funded by this grant? If so, which organizations? We would welcome introductions to organizations in Cupertino as collaborators on this project and to support other online teaming projects in the City. We would like to collaborate with the City on content selections and the best ways to engage the community with existing assets. 18, If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants, please describe this support: N/A 19. Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of progrem/projectlevent(e.g.fee walvere)? If so, please describe this anticipated support N/A 20. If you are a multHurisdictional organization, describe any funding requested from other agencleslorganizations in regards to this program/projectlevenl request. Indicate whether the funding was granted, denied, or Is still pending: N/A for this prograntlproject. CumikiStudio receives funding from several foundations and individual donors to support our mission. 21.How would you fund the program/project/event It you do not receive the requested funding?: We would not move forward with this project without funding. SECTION 5: PRIOR FUNDING 1. If you received a Community Funding Grant in prior years.indicate the amounts for each year and describe how those funds were used: 2. If you received a Community Funding Grant last year. a. Please provide a line item breakdown of how the Community Funding Grant was used last year in the categories below. If a category is not applicable. put$0: I.Admin Staff ii. Matenals/E ui ment 'ii. Entertainment 'v. RoomNenue Rental .Other Professional Services Other Total $ b.Who was served by the grant last year? i. Number of individuals total' it Number of Cupertino residents: iil. Particular community groups is.Was the program/project/event available to the entire community/public or are there any eligibility criteria? v.Was there a charge or fee for the prograndprojectlevent(if applicable)7 vi.What outreach methods did your organization use to promote the program/project/event(if applicable)? c.Was the program/project/event successful?Please indicate how success was measured: 3. Please indicate any additional funding received last year from other sources and provide your financial statement if available: Attachments: Attach your financial slatment, and any other helpful information about your project. Fy2021 financial statement for the most recently completed fiscal veaff, f Cumkl Executive Summary January 2021.pdf Program Manager Signature CAO/CMO Date Signed 01129/2021 Currild Currik€ Profit and Loss Profit and Loss FY202D FY2021 July,2D20 July 2019•June 2020 July,2020 Income Total income Total 4015 Contributions-Unrestricted 461,199.06 4015 Contributions-Unrestricted 410,997.00 4210 Corporatelbusiness grants 275,000,00 4210 Corporatelbuslness grants 0.00 4400 Sponsorship Revenue 30,000.00 4400 Sponsorship Revenue 0.00 Total 4000 Contributed support $ 766,199.06 Total 400D Contributed support $ 410,997.00 4300 Gifts in Kind 137,097.58 4300 Gifts in Kind 0.00 5310Interest-Savings 684.261, 5310Interest-Savings 35.22 Total 50DO Other Income $ 684.26 Total 5000 Other Income $ 35.22 Total Income $ 904,880.90 Total Income $ 411,032.22 Gross Profit $ 904,880.90 Gross Profit $ 411,032.22 Expenses Expenses 7200 Salaries&related expenses 531.701.45 7200 Salaries&related expenses 42,698.56 7220 Salaries&wages-other -76,000.00 7220 Salaries&wages-other 0.00 Total 7200 Salaries&related expenses $ 465,701.45 Total 7200 Salaries&related expenses $ 42,698.66 7340 Employee benefits 61,590.20 7340 Employee benefits 3,948.66 i i 7350 Payroll taxes 34,891.06 7350 Payroll taxes 2,771.73 7360 Workers Comp 2,647.47 7360 Workers Comp 178.67 i 7370 Annual Leave 4,226.38 7370 Annual Leave Total 730D Benefits and other salary related expenses $ 103,355.10 Total73DO Benefits and other salary related expenses $ 6,897.06 7520 Accounting&Business Fees 16,691.91 7520 Accounting&Business Fees 1,018.60 8520 Business Insurance 7,421.20 8520 Business Insurance 4,574.73 8530 Membership Dues&Subscriptions 6,827.69 8630 Membership Dues&Subscriptions 8680 Filing Fees 17040 8600 Filing Fees . Total 7520 Accounting&Business Fees $ 30,110.80 Total 7520 Accounting&Business Fees $ 5,594.33 Total7500 ProfessionallBusiness&Accounting $ 30,110.80 Total7500 Professional/Business&Accounting $ 5,594.33 7600 Contractors 3,360.00 7600 Contractors 7610 Administration-Contractors 42,790.00 7610 Administration-Contractors 5,620.00 7620 Content-Contractors 7,939.00 7620 Content r Contractors 2.742.00 1 7630 Portal-Contractors 281,316.32 763D Portal-Contractors 65.890.86 Total 76DO Contractors $ 335,405.32 Total 7600 Contractors $ 74,252.06 7700 Public Relations&Marketing 53,097.72 7700 Public Relations&Marketing 3.968.93 7535 Legal Fees-Gifts in Kind 22,412.50 7535 Legal Fees-Gifts In Kind 0.00 7710 PR1Marketing-Gifts in Kind 08,770.02 771D PRIMarkating-Gifts In Kind 0.00 8020 Host€nglNetwork Services-Giftt:In Kind 16.815.06 8020 Hosting/Network Services-Gifts in Kind 0.00 Total 7800 Gifts-In-Kind $ 137,997.58 Total 7800 Gifts-in-Kind $ O.OD 8095 Platform Support&Maintanance 12,837.16 8095 Platform Support&Maintenance 102.25 Total 8000 Platform Support&Maintenance Expenses $ 12,837.16 Total 8000 Platform Support&Maintenance Expenses $ 192.25 8110 Office supplies and equipment 3,314.55 8110 Office supplies and equipment 8130 Telephone&telecommunications 4.835.11 8130 Telephone&telecommunications 77.16 8140 Postage,shipping,delivery 941.76 8140 Postage,shipping,delivery 8160 Equip rental&maintenance 141.00 8160 Equip rental&maintenance 8180 Books,reference .39.99 8180 Books,reference Total 8100 Office Expenses $ 9,272.41 Total 8100 Office Expenses $ 77.16 8310 Travel 15,519.81 8310 Travel 8320 Meals&Entertainment 1,458.22 8320 Meals&Entertainment 8330 Seminars&Conferences 0.00 8330 Seminars&Conferences Total8300 Travel,Entertainment,Meetings $ 16,978.03 Total8300 Travel,Entertainment,Meetings $ O.DO Total Expenses $ 1,154,755.57 Total Expenses $ 133,681.15 Net Operating Income $2449,074.67) Net Operating Income $ 277,361.07 Net income ($249,874.67) Net Income $ 277,351.07 Build what you want the future of learning to be Currild is the world's first free and open,interactive learning content development platform designed to accelerate and scale digital the creation of digital learning experiences to help students learn more effectively. Key Success Factors The Rise in Virtual Education • 12 year leader in creating free and The state of education went digital overnight as we faced the onset of a global open educational resources. pandemic.The world learned what educators knew instinctively;we were not prepared • Supporting K-1 2.Higher Ed to support Poll digital learning programs at scale.The deficits are many;including the corporations,and nonprofits. lack of comprehensive tools and dynamic curriculum. Today's lessons are designed for • Robust lead generation capabilities a traditional classroom setting and are stuck in static PDFs.The result.Students report with minimal support services they are less engaged with online learning and teachers lack the ability to deliver metlia. interactive learning.With these current challenges,educators and administrators • service netwto suprk port certifies across all sectors are searching for ways to create Interactive content designed for services to support partners. • Lean operating budget with tligital learning experiences.With over 200,000 education technology tools available, expenses focused on tech this task has proven to be time consuming and expensive. development and scale. Our Team&Advisors The Future of Learning, All in One Place Our andersmo team combines Curriki is a non-profit organization that has been revolutionizing the way digital learning decades of experience in cement is distributed and openly shared for over a decade-In July 2020,we launched eernmemeurshipavienuoaaon. CurrikiStudio,a free full-service learning content authoring suite designed to help • Team includes: educators create dynamic and engaging curriculum online.Without any coding o Abby Ross,CEO knowledge required.CurrikiStudio makes every aspect of the process simpler,faster, and affordable.We aim to empower educators create,publish and evaluate immersive o Leo Cunha,CTO learning experiences online in an effort to engage students In a more meaningful way. o Janet Pinto,CM0 The early success of Curtin Studio has introduced the opportunity to expand this open • Board of Directors Includes source projem to businesses looking to engage employees and customers. Scott McNealy,Kim Jones ._ - • _ (Sun Microsystems),Bill Raduchel(AOL). Supporters of Curriki a. amain supporters are some of the wood'a Easy conshatt creation 50+activity types like Creators publish IeadlogledmoloW companies and tools for building Interactive video,360 interactive playlists, foundmions. lessons tours,drag&drop accessible on any device VAT&T gy+w^ CumkiStudm has gained traction across K-12,higher ad.and corporations with leading organizations such as ASU,Baylor,Teach for America.Dallas Ii PGA,Salesforce,and several state DOES. oaac3_e birdies Scaling Impact in Education We are leaning into the vast changes required to support education needs in 2021. aWS IMAM"Foundation To continue our efforts we are raising$2M from generous donors who are passionate about sponsoring new learning experiences and curriculum campaigns. Learn more at curr k om/roadmao-v s'on Curriki (NEW) Eligibility Checklist (staff use only) EligLbility YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the' X program/project/event Identify how the funds will be used to benefit the Cupertino X community Be awarded only once per project X Fors specific need s,ds,not ongoing,operational costs X Have more than 75%of the requested funds allocated for direct X 26%or more of the requested funds were allocated toward expenses not directly service costs versus administrative costs tied to the proposed program/event/project(i.e.:organizational staffing costs) Be complete and submitted by the application deadline X js Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only NA submit one application Proceeds generated from the funded activity may only be used for the conducted activity NA admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved " NA by Parks and Recreation Commission City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Community Funding Grant in the past? O Yes 0 No If, Yes,when? 2010, 2013-2020 S!7.-T*N 1: CONTACT INFORMATION Legal Dame of Friends of Deer Hallow Farm Organization: Web Address: www.deerhollowfarmfriends.org Mailing Address: PO Box 4282 City: Mounlain View Zip: 94040 Phone: President/Executive Lauren Merriman Title: President Director: Email: Telephone laur.en@dcerhollovvfarmfriends.org Number: Contact Person: LaLlrern Merriman Title: Email Address: lauren deerhollowfarmtriends.or P Tele hone gNumber: SECTION 2: NON-PROFIT INFORMATJOI'' 501(c)(3)? * Yes O No Year Established 1994 Federal Tax la: Fiscal Sponsor Name: N/A Fiscal Sponsor Address: City, Zip: Phone: SECTION 3: ORGANIZATION INFORMATION Total Organization Budget: $492,049 Total#of Board Members: 8 Total#of staff: Total#of Volunteers: 20 Mission Statement: To preserve Deer Hollow Farm as an educational center and working farm, and support the Farm's environmental education programs for the benefit of schools and the community by raising funds through donations, grants and events, Brief Description of Organization.- Deer Hollow Farm is a 160 year-old historic ranch located in Rancho San Antonio County Park and Open Space Preserve, immediately west of Cupertino. Its mission is to provide environmental education and historical programs for the community, Friends of Deer Hallow Farm is an all-volunteer, non-profit 501(c)(3) organization that has supported Deer Hollow Farm's outstanding educational programs and facilities since 1994. Brief Description of Services Provided: Deer Hollow Farm is an educational center where the public, school classes, and community groups ran participate in a historic working farm. No entrance, parking, or admission fees are charged to the public. The Farm is home to over 100 live farm animals. Without these animals, the Farm would not be a living history center, but rather a museum of old farm buildings. The Farm animals and the Farm's environmental education program teach the community about: - Value of protected land and wildlife - Sources of food and other daily-used products (soap, wool) - Principles of recycling and avoiding waste - Interdependence of all life - Culture and history of the Say Area's Native American Ohlone people Since 1976r the Farm has offered environmental education classes to elementary-age students across Santa Clara County and the Peninsula. These outdoor classes are so popular that a lottery is held annually for the 5.000 available spaces. The classes reinforce State elementary SECTION 4: GRANT REQUESTS �. 1.PrograMProject/Evenl Name: Deer Hollow Farm-Demonstration Garden 2. Date(s)and/or duration of program/projectlevent(if applicable):Once Funded 3,Total program/project/event budget: $7.000 4, Requested Amount: $7.000 Percent of total prograMprojectlevent budget: 100% 5. Program/Project projected income: $0 Percentage of your organization's projected income: 0% 8.Type of Request: O Capital Improvement D Program Support O Event 6 One-time project 0Other: 7.This grant will fund a(ri Existing program/project/event;established in(year) 0 New program/project/event 8.Describe the purpose of requested funds and the services that will be provided: We plan to build a completely enclosed garden space that will house five large raised metal growing beds.The outside,wooden frame structure will be enclosed on the top, bottom and sides with hardware cloth and paneling to prevent animals from entering. One key benefit of this design:we will no longer have to utilize traps and cages to deter gophers and other small animals from invading the garden.The enclosed garden will extend from the farm'a entrance along one side of the while barn.This location is very accessible to the general public and school groups as they head in or out of the famr In addition, it is optimally situated for the most sunlight in all vegetable growing seasons. Finally, the existing garden will be modified to feature native plants and function as a life science demonstration location. We plan to build several log mlling/insect stations to augment our current life science education during the school year and summer camp. 9. Please provide a line item breakdown of how the funds will be used in the categories below. If a category is not apiplicable, put $0: IRdmin Staff aterials/E ui ment $7,00ntertainment oonni Rental ther Professional Services her 1 - $7,00 10. Explain how the request aligns to City mission and values: Providing support for improvements to Deer Hollow Farm is a perfect fit with the City of Cupertino's goal of enhancing its residents lives with greater open space opportunities and high quality, hands-on educational opportunities. 11. Describe how the program/projecievent fills a community need.Who identified this need?What other similar project/program/event exists to serve Cupertino residents? How is your proposed projecuprogram/event unique from similar projects/programs/events or how do you collaborate to avoid duplication? Deer Hollow Farm is a unique asset to the South Bay as a whole, and especially so to nearby cities such as Cupertino. It provides bath an environmental learning experience for elementary school-age children and a living farm environment for multi-generational families.As at any other farm or ranch, McClellan Nature Preserve for example, the location and utilization of our resources for out visitors experience are Important. The need was identified by Senior Farm Staff,who have determined the current teaching garden is in a poor location for student/public access and lacks sufficient sunlight to thrive during the growing season.This garden space will be accessible to all visitors of the Farm due to it's improved central location, 12. Who will be served by this grant? All visitors to Deer Hollow Farm will benefit from this demonstration garden. a)Number of individuals total: 105,000 b)Number of Cupertino residents: 12,000 of Particular community groups: Elementary school children (educational farm tours)and families with children. d)Will the program/project/evenl be available to the entire community/public or are there any eligibility criteria? i Deer Hollow Farm is open to the entire community and public. The environmental education program is open to classes from all elementary schools in the South Bay and Peninsula_This is subject to COVID-19 restrictions and our capacity. e)Will there be a charge or fee for the program/project/event if applicable) There are no entrance or parking fees for visitors of Deer Hollow Farm. The City of Mountain View charges a fee for environmental education classes during the school year, but FoDHF sponsors a scholarship program that covers all costs including transportation for schools designated as low-income per the National School Lunch Program guidelines. 0 What outreach methods does your organization use to promote the program/project/event(If applicable)? FoDHF maintains an active website(www.dearhollowfarmiriends.org), produces two newsletters annually,and is active on social media(Facebook and Instagram). Foi also participates at many local community events, including the Silicon Valley Fall Festival and Earth Day events in Cupertino,Thursday Night Live in Mountain View, and the Volunteer Parade in Sunnyvale.Working with the Mountain View employees who manage the Farm, FoDHF helps to staff annual fundraising events at the Farm. 13. Describe how the funds will be used to benefit or impact the Cupertino community: In 2013-14, we performed a quarady survey of Farm visitors identifying their home zip code. Based on that study, Bay Area citizens visit the Farm more Man 100,000 times annually, with 11,800 visits to the Farm by Cupertino residents.There is no reason to think that Mese numbers have reduced since 2013-14. Considering the population of Cupertino, many residents avail themselves of the Farm and Rancho San Antonio. Cupertino's Parks System Master Plan identifies a high resident priority for access to open space and trails.The Farm and Rancho San Antonio greatly augments City resources.This grant funds a meaningful enhancement to our site benefaing all visitors. DHF hosts an extensive Farm Tour program for school students. In 2019-2020, DHF served 14 classes from CUSD schools in Cupertino, for a total of 397 students.These students attend LP Collins, Eaton,Garden Gate,and Stevens Creek schools. The Farm also hosted 11 classes from other CUSD schools with non-Cupertino addresses. 14. Demonstrate that the member implementing and managing the program/project/event have adequate experience: Our Board of Directors include business leaders,community leaders, educators,and financial professionals. The Farm hosts volunteers that spans high school students, working adults, to retirees.They bring rich experiences as educators,executives, and artists. In addition,we work closely with non-FoDHF professional farm staff including educational program staff and an on-site farmer from the City of Mountain View, and Rangers and Maintenance Workers employed by the Mldpen Open Space District. Deer Hollow Farm is operated by a partnership between Midpeninsula Regional Open Space District, County of Santa Clara, City of Mountain View,and FoDHF.We are fortunate to have the support of a huge team who love and are dedicated to the success of Deer Hollow Farm.This specific project will be executed by trained maintenance workers that are employed by Midpen Open Space District. 15. How will success of the program/projecUevent be measured?: Success will be measured by the successful completion of the demonstration garden. Once in-person classes can resume,another measurement will be the number of classes in attendance and eventually when a new Farm visitor survey can be completed we will have new data to understand the benefit to all communities in the larger Bay Area. 16. Will more than 75% of the requested funds go towards direct service costs versus administrative costs? 0 Yes O No 17. Will you collaborate with other organizations to deliver the program/project/event funded by this grant? If so, which organizations? Improvement projects at Deer Hallow Farm are implemented by a permanent partnership between FoDHF, the City of Mountain View which operates the Farm, the Midpeninsula Regional Open Space District which owns the land and buildings at the Farm, and the County of Santa Clare who own the outer county park area.This has been true for many years and will continue Indefinitely. 18. If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants, please describe this support: FoDHF has not received any support from the City of Cupertino outside of the Community Funding Grant program. 19. Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of program/project/event(e.g.fee waivers)? If so, please describe this anticipated support: No, there is no expectation of any funding from the City of Cupertino outside of the Community Funding Grant in this application. 20. If you are a multi-jurisdictional organization, describe any funding requested from other agencies/organizations in regards to this program/projectlevent request. Indicate whether the funding was granted,denied,or is still pending: We have applied for and received grants from other foundations,government entitles, and other supporters of the Farm In forms which are not restdcted to the demonstration garden but may be applied to this project. 21. How would you fund the progran✓projecttlevent If you do not receive the requested fundingi FoDHF would seek donations from other sources, including other governments, local foundations, and the general public. Foi enjoys a broad base of support. In the past four years,we have received support from the following. organizations(to name a few): -City of Cupertino -Town of Los Altos Hills -County of Santa Clare •Packard Foundation -Mayfair Foundation -Gordon&Befty Moore Foundation -Los Altos Community Foundation -Los Altos Rotary Endowment Fund - Mountain View Kiwanis Foundation -Serene Properties Foundation(1% for Good Recipient) - Intero Foundation ECTION 5: PRIOR FUNDING 1.If you received a Community Funding Grant in prior years, indicate the amounts for each year and describe how those funds were used: FoDHF has received Community Funding Grants approved by the City Council in previous years: -FY11:$5.000 -FY12: $5,000 -FY13:$10,000 -FY14:$10,000 -FY15:$10,000 -FY16:$10,000 •FY17:$15,000-funded new fencing for pig and goat pens, new and upgraded tools and farm equipment -FY18:$15,000-funded remodel of garage/workshop,new storage structures and barn painting -FY19:$15,000-funded upper pasture barn (supporting our on-site breeding program), new gate,new signage- FY20:$15,000-funding White Barn Renovation project Through FY16, 100%of these amounts were used to help fund the operations of the Farm.After FY16,the City changed its procedures to require Community Funding Grants to name specific infrastructure projects to be funded. For details, consult the grant requests for those fiscal years. 2. If you received a Community Funding Grant last year: a. Please provide a line item breakdown of how the Community Funding Grant was used last year in the categories below, If a category is not applicable, put ii .Admin Staff $ 1. Materials/Equipment $15.00 ii. Entertainment S v. Room/Venue Rental S .Other Professional Services 0 $ . Other $ total $15,00 Is.Who was served by the grant last year? All visitors to the Farm are served by infrastructure improvements of the White Barn. In FY20,spending was primarily on pre.construction research and design efforts.The construction and stabilization of the While Barn is in its final stages of completion and anticipate site-work to be done in March 2021, i. Number of individuals total: 105,000 ii. Number of Cupertino residents:12000 iii. Particular community groups Elementary school children (farm lours); families and walk-in visitors iv,Was the program/projeclAwenl available to the entire community/public or are there any eligibility criteria? The Farm facilities are available to the publi"t-large with no entry or parking fees.School farm tours include fees set by the City of Mountain View, but more than 50% of our student visitors attend free of charge, thanks to a FoDHF scholarship program available to schools that meet federal criteria as low-income schools. v.Was there a charge or fee for the progranJprojectlevent(if applicable)? No.Admission to Deer Hollow Farm is only charged four days per year when we hold fundralsing events to support the Animal Fund. vi.What outreach methods did your organization use to promote the prograMproject/event(if applicable)? We conducted outreach for White Barn donations through directed efforts with our Grants subcommittee and in general donation appeals to our membership list. During the construction, we have been actively sharing progress of the project through our social media channels. c.Was the program/projectrevent successful? Please indicate how success was measured: Yes,the While Barn project work has been successful FoDHF funding has paid for things such as documentation of the site and facility, historical structure study, initial plan development, and project cost analysis.There were significant unplanned expenses for a study of ADA requirements for historic structures. Overall, FoDHF provided $195.000 towards this large project with the help of the City of Cupertino Community Funding Grant, 3. Please indicate any additional funding received last year from other sources and provide your financial statement if available' As indicated above, Foi receives funding from many sources, including other government entities, nonprofit foundations, and the general public. Attached are the FoDHF income statements for: - FY20,ending 6/30/2020 Attachments:Attach your financial statment, and any other helpful information about your project. FoDHF Demonstration Garden Project Expenses 2021-2022 gdf FODHF Enhancement Proposal 2021- Garden Images fldf FoDHF 2021 Grants - FY20 Results FY21 Budget.pdf Program Manager Signature President, Friends of Deer Hollow Farm Date Signed 01/31/2021 FRIENDS OF DEER HOLLOW FARM Financial Results Bud et Statement of Activity&Financial Position Twelve Months Ended 6/30/2020 Fiscal Year 2021 Cash Basis-Unaudited General I Restricted Total General I Restricted Total REVENUE Support Grant Revenue $ 3,000 $ 50,078 $ 53,078 $ - $ 51,500 $ 51,500 Direct Public Support 65,064 39,294 104,358 66,000 26,000 92,000 Cash donations at the Farm 640 - 640 1,000 - 1,000 Total Support 68,704 89,372 158,076 67,000 77,500 144,5130 Fundraising Events,net Ohlone Day (500) 1,470 970 - - - Spooky Time - 2,860 2,860 - - - Spring Tour - - - (1(10) 7,100 7,000 Classes&Other - - - (600) 4,600 4,000 Total Fundraising Events,net (500) 4,330 3,830 (700) 11,700 11,000 Sales,net 1,271 500 1,771 1,000 - 1,000 Investment Income 16,228 16,228 11,000 - 11,000 TOTAL REVENUE 85,703 94,202 179,905 78,300 89,200 167,600 EXPENSES Marcomm,Web&Social Media 3,279 - 3,279 4,500 - 4,50D Donor Relations 46 - 46 1,150 - 1,150 Liability Insurance 2,890 - 2,890 3,000 - 3,000 Accounting Consultant 5,464 - 5,464 10,000 - 10,000 Office Supplies&Other Expense 1,338 293 1,631 1,625 200 1,825 TOTAL EXPENSES 13,016 293 13,310 20,275 200 20,475 NET REVENUE 72,686 93,909 166,595 58,025 89,000 147,025 Grants Awarded Scholarship Program - 18,590 18,590 - 35,000 35,000 Deer Hollow Farm-Animal Care 11,192 40,978 52,170 10,300 41,500 51,800 Deer Hollow Farm-Operations 15,000 11,518 26,518 15,000 12,500 27,500 Deer Hollow Farm-Enhancements 14,895 29,799 44,693 6,600 10,000 16,600 MROSD-White Barn Project - 166,000 - 166,000 Deer Hollow Farm-YouthlOther Projects 1,152 - 1,152 2,000 - 2,000 TOTAL GRANTS AWARDED 42,239 100,884 143,123 199,900 99,000 298,900 CHANGE IN FUND BALANCE 30,447 (6,975) 23,472 (141,875) (10,000) (151,875) CASH &INVESTMENTS AT: BEGINNING OF PERIOD 461,602 34,383 495,985 492,049 27,408 519,457 END OF PERIOD $ 492,049 $ 27,408 $ 519,457 $ 350,174 $ 17,408 $367,582 Unrealized Gain(Lass) 21,709 Total Cash&Investments at FMV at: 6/30/2020 $ 541,166 Included in General Fund Balance above: Board Designated-White Barn $ 165,881 Cash Basis- Unaudited Friends of Deer Hollow Farm Proposed Enhancements Budget 2021-2022 Item Vendor Price/item duantity Cost S&H 10% Tax 9.25% Total Metal Doors 36X80 Home Depot $ 170.00 2 $ 340.00 $ - $ 31.45 $ 371.45 Hardeware cloth 4X100 ft Home Depot $ 177.00 13 $2,301.00 $ - $ 212.84 $ 2,513.84 Oval Galvanized Stock Tank,3x 8x 2 ft.H,Wf328 Tractor Supply $ 289.99 5 $1,449.95 $ - $ 134.12 $ 1,584.07 PT Lumber 4X6X1Oft Home Depot $ 32.00 21 $ 672.00 $ - $ 62.16 $ 734.16 Paint,5 gallon Home Depot $ 95.00 3 $ 285.00 $ - $ 26.36 $ 311.36 Cement bags Home Depot $ 5.25 63 $ 331,00 $ - $ 30.62 $, 361.62 Hardware(hangers,screws)*estimate Home Depot $ 350.00 $ 350.00 Clear polycarbonate panels Home Depot $ 20.00 20 $ 400.00 $ - $ 37.00 $ 437.00 2X4X16 Lumber Home Depot $ 22.00 10 $ 220.00 $ - $ 20.35 $ 240.35 a FODHF Enhancement Proposal 2021.22: Barnyard Entry Garden A:Front view of the garden enclosure. The building length is 32 ft,width is 8ft.Roof lowest height is 7 ft. Doors are 4 feet wide. B:Side View C:Example of the finished construction dd 9 1 FFF 10 > , l _ M Nm�� !! 1 C B Deer Hollow Farm (Returning) Eligibility Checklist (staff use only) Eligibility YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/project/event Identify how the funds will be used to benefit the Cupertino X community Be awarded only once per project X For specific needs,not on going,operational costs X Have more than 75%of the requested funds allocated for direct service costs versus administrative costs . X Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only submit one application NA Proceeds generated from the funded activity may only be used for the conducted activity NA admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved NA by Parks and Recreation Commission City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Community Funding Grant in the past? O Yes O No If, Yes,when? 2020 Legal Name of Organization: Santa Clara Valley Audubon Society Web Address: scvas.org Mailing Address. 22221 McClellan Road City: Cupertino Zip: 9d014 Phone; President/Executive director:Matthew Dodder Title: Executive Director Email: Telephone Number: director scvas,org Contact Person: Matthew Dodder Title: Executive Director Email Address: director@scvas.org Telephone Number: 501(c)(3)? * Yes 0 No Year Established 1977 Federal Tax ID: Fiscal Sponsor Name: Fiscal Sponsor Address; City: Zip: Phone: SECTION 3: ORGANIZATION INFORMATION Total Organization Budget: $519,469 Total # of Board Members: 10 Total # of staff, 7 Total # of Volunteers: 100 Mission Statement: The Santa Clara Valley Audubon Society promotes the enjoyment, understanding, and protection of birds and other wildlife by engaging people of all ages in birding, education, and conservation. Brief Description of Organization: The Santa Clara Valley Audubon Society, founded in 1925, brings together people who care about birds and nature. Based in the heart of Silicon Valley, SCVAS has supported birding adventures and environmental education for nearly a century. Its dedicated members and staff play a critical role in protecting local birds and their habitats by working to promote environmental resilience and sustainability in the Bay Area. Our volunteers and staff work hard to: 1. Provide opportunities to experience and appreciate the beauty of birds and their place in the natural world. 2. Educate our region's diverse population about the importance of preserving open spaces for both wildlife and our own well-being. 3. Promote scientifically-sound strategies to protect and restore wildlife threatened by loss of habitat and safe migration corridors. 4, Collaborate with other Audubon chapters, conservation organizations, and local businesses and governments to achieve our common goals. Brief Description of Services Provided: Our services are divided into three main areas: Conservation, Education, and Birding 1, Conservation: SCVAS works to protect local birds and wildlife through our provision of nest boxes for threatened cavity nesters, management of breeding habitat for endangered Burrowing Owls, annual bird counts to track avian population trends, and advocacy on behalf of open spaces, bird-safe building design, and wildlife-friendly habitat in urban areas, 2. Education:We provide environmental education to people of all ages from elementary students through seniors in our school-based programs, family field trips and excursions, volunteer projects, adult classes,and publications, 3. Birding: We encourage environmental stewardship with our free birdwatching trips, bird photography events and classes, nature speaker series, bio blitzes, and summer programs for kids.As we inspire people to care about birds,we deepen their appreciation of the natural environment that sustains all SECTION 4: GRANT REQUESTS 1. Progmm/PrajecVEvent Name: Wildlife&Harvest Festival 2. Date(s)and/or duration of prograMprolectfavent(if applicable):Saturday, October 23—Sunday,November 28 3.Total programfprojectlevent budget: $17,000 4. Requested Amount: $8.500 Percent of total program/projecUevent budget: 50% 5. Program/Project projected income: $0 Percentage of your organization's projected income: 0% 8.Type of Request: ❑Capital Improvement ❑Program Support 0 Event ❑One-fime project D Other:Annual Event, now converted to video format for COVID pandemic 7.This grant will fund a(n): 0 Existing progra"project/event;established in 1991(year) C) New program/projecVevent B. Describe the purpose of requested funs and the services that will be provided: The funds will be used to purchase the equipment and professional services needed to produce high-quality video content far a month-long Wildlife and Harvest Festival showcasing Cupertino's parks and open spaces and the critical work local grass-roots environmental organizations. In the past this has been a daylong in-person event, but with advent of the pandemic we moved to an online format.We found this to be an incredible opportunity to reach a far broader audience than in the past.This coming year we plan to enhance our offerings with video visits to many of our favorite Cupertino wildlife hat spots and by bringing in new exhibitors who share our mission of inspiring people to care about the natural world that sustains us all. 9. Please provide a line item breakdown of how the funds will be used in the categories below. If a category is not aplaficii1ble. put$0: Armin Staff $0 b MateriasdE ui ment $8,500 Entertainment $0 Room/Venue Rental $0 Other Professional Services Video limiduction $0 Other $ Total $6,50 10. Explain how the request aligns to City mission and values: Wildlife & Harvest Day aligns with several priorities articulated by Cupertino residents through the City's community outreach process. The event creates opportunities for members of varied cultural backgrounds to learn about nature in a COVID-safe and interactive way. It appeals to multigenerational families by offering engaging video content and activities for all ages from tots and teens to older adults. Because the festival is held in partnership with the City of Cupertino and many other participating environmental and wildlife organizations, it is well aligned with the City's desire to build partnerships while providing residents with diverse recreational activities. 11. Describe how the program/project/event fills a community need.Who Identified this need?What other similar project/program/event exists to serve Cupertino residents?Haw is your proposed project/program/event unique from similar projects/programs/events or how do you collaborate to avoid duplication? SCVAS's video festival addresses two important needs.The first is the need that almost all of us feel to connect more with nature, particularly in times of stress.The second is desire of local environmental organizations to share their resources, vision,and opportunities for engagement with the broader Cupertino community and beyond. Our COVID-induced shift from a physical event to an extended online festival has enabled us to engage many more attendees,with each visitor finding an exciting collection of guided arts and crafts activities along with engaging educational content suitable for all ages. This coming year we plan to expand our focus beyond McClellan Ranch and Blackberry Farm to other local wildlife-viewing hotspots including Rancho San Antonio Preserve, Stevens Creek County Park, Linda Vista Park, Cupertino Memorial Park,the McClellan Groundwater Recharge Pond, 12. Who will be served by this grant? The festival serves the Cupertino community and teachers by promoting natureroriented opportunities in their immediate areas. Exhibitors benefit from the opportunity to reach new audiences, supporters and volunteers. It Is hard to predict just how many Individuals will be served because of the online format. In 2020 our videos were viewed by at least 1080 visitors. We have no way of knowing whether any given visit involved a solo viewer, a family group, Scout pads, or fourth-grade classroom. a)Number of individuals total: 1,080 b) Number of Cupertino residents: 0 c) Particular community groups: The event has always focused on Cupertino residents,we'll continue to promoting our next Wildlife Festival locally. The in-person event has always attracted large multi-generational family groups.Our online festival has attracted interest from elementary school teachers,4H clubs, Girl Scout troops, master gardeners, native plant enthusiasts, mobility limited nature lovers. backyard birders, amateur naturalists, students interested in green careers, adults looking for volunteer opportunities d)Will the program/projecVevent be available to the entire community/public or are there any eligibility criteria? The festival is open to everyone. e)Will there be a charge or fee for the progrem/project/event(if applicable) No. f)What outreach methods does your organization use N promote the program/project/event(if applicable)? We will promote the 2021 festival though our quarterly newsletter, monthly email updates,website, invitations to schools we serve with our educational programs,as well as public notices on local bulletin boards. Nextdoor, and local libraries and businesses.We will also post information on social media channels Including Facebook and Instagram. We hope to grow our online audience by building on our 2020 experience to create more compelling and varied content. 13. Describe how the funds will be used to benefit or impact the Cupertino community: Cupertino is blessed with a wealth of open spaces and native wildlife as well as non-progt organizations that share our desire to inspire people to explore the nature[world around us. Our goal is to help all who live here to see, hear, and experience the natural wonders close to their homes—the birds, mammals, plants,and trails. By introducing our community to citizen science activities such as Project Feederwalch,engaging our children with animal-related crafts, and enticing both young and old to visit our parks and walk our trails,we aim to enhance the lives of both the people and the wildlife who call Cupertino home. 14. Demonstrate that the member implementing and managing the program/projecVevent have adequate experience: SCVAS staff and volunteers began organizing Wildlife Education Day in 1991. Our 30 years of experience at mounting this festival with Its many moving pads was a factor in the City of Cupertino's decision in 2016 to join with - SCVAS to create Wildlife&Harvest Day.Our current staff brings a wealth of experience in environmental education, online content development,event planning and marketing, managing exhibitors and venders,and in recruiting and training legions of student and adult volunteers. 15. How will success of the program1project/event be measured?: Our web server provides metrics on visitor traffic which we have seen increase by doubledlgits during the festival. We also receive detailed analybcs from YouTube regarding unique views, likes, etc. We also measure success in terms of exhibitor satisfaction. Most tell us that they choose to return year after year because they are so pleased with the increased exposure and Interest they see during the festival. While most of our exhibitors are based in Santa Clam and San Mateo counties,we draw some from as far away Martin and Sonoma counties. In addition, we gather anecdotal evidence of success from viewers who make a point of telling us how much enjoyed the event, how much they learned, and that they look forward to future festivals. 16. Will more than 75%of the requested funds go towards direct service costs versus administrative costs? O Yes O No 17.Will you collaborate with other organizations to deliver the program/project/event funded by this grant? If so, which organizations? We partner with the City of Cupertino and its Environmental Services Department to host this event.We also invite other organizations to host information and activity booths including: Bay Area Herpetological Society Cavity Nesters Recovery Program Cupertino Green Environmental Volunteers Felidae Conservation Fund Friends of Stevens Creek Trail Grassroots Ecology Guadalupe River Park Conservancy Marine Science Institute Mickaboo Companion Bib Rescue Midpeninsula Regional Open Space Dist. Our City Forest Palo Alto Junior Museum &Zoo Palomacy Pigeon& Dove Adoptions Santa Clara Valley Beekeepers Guild Santa Clara County Open Space Authority UCCE Master Gardeners of Santa Clara County Wild Cat Educ 18. If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants, please describe this support: We have not received such funding. 19. Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of program/project/event(e.g.fee waivers)? If so, please describe this anticipated support: No 20. If you are a multi-Jurisdictional organization,describe any funding requested from other agencies/organizations In regards to this program/project/event request. Indicate whether the funding was granted, denied,or is still pending: We do not currently have any other grant requests pending to fund this event. 21. How would you fund the prograMproject/event if you do not receive the requested funding?: If we do not receive the requested funding,we will use donations from our members to partially fund the event and seek other grant opportunities. If no other funding is secured, we will have to consider scaling back or cancelling next fall's festival. SECTION 5: PRIOR FUNDING 1. If you received a Community Funding Grant in prior years,indicate the amounts for each year and describe how those funds were used: SCVAS received a Community Funding Grant for the Wildlife and Harvest Festival in 2019 for$10,000,which covered roughly half of our costs in planning and staging the event.This grant enabled us to improve our varied offerings at the festival despite our own budget constraints and in the face of rising program costs. In 2020 we received$7500 for a physical event, but due to COVID We converted it to an all virtual, month-long video festival. Expenses included equipment needed for produce video content. Other direct costs included staff time and expertise need to recruit exhibitors;to film,edit, and produce online video content; and to promote the festival in its new format. 2. If you recelved a Community Funding Grant last year: a. Please provide a line Item breakdown of how the Community Funding Grant was used last year In the categories below. If a category is not applicable, put$0: I. Admin Staff $9,281 ii. Materials/Equipment $270 ii. Entertainment v. Room/Venue Rental v. Other Professional Services . Other Total $9,551 b.Who was served by the grant last year? We had well over 1080 unique visitors to the video festival. i. Number of individuals total: 1,080 ii. Number of Cupertino residents: If. Particular community groups Not available due to the online nature of this festival. We can only assume that the majority were Cupertino residents as that where we focused our promotion. iv.Was the program/projectlevent available to the entire community/public or are there any eligibility orders? We promoted it widely in the immediate community,but we also expanded it to Santa Clara County as a whole. With every view,attendees were exposed to local non-profit organizations in the wildlife and environmental arena, and each exhibitor was given valuable exposure to community members of whom they may not have been aware of or fully understood. v.Was there a charge or fee for the program/project/event(if applicable)? The event has always been free to attendees. vi.What outreach methods did your organization use to promote Me program/projectlevent(if applicable)? We approached schools, posted on local bulletin boards, Nextdoor,Libraries, etc.,we hoped to attract members of the local community. We will also promote beyond these channels with Facabook and Instagram and our entire county-wide membership. c.Was the progranviprojectlevent successful? Please indicate how success was measured- We have always considered the event successful,due to the enthusiasm and excitement of allendees young and old. With the shift toward virtual,we did not know what to expect. We feel it was enormously positive for the community,spotlighting local opportunities for rich outdoor and wildlife learning experiences, as well as the activities of dozens of local environmental,animal,and community-service programs such as Midpeninsula Open Space,Open Space Authority,4 h, Girl Scouts, Bee Keepers,and Master Gardeners,just to name a few. 3. Please indicate any additional funding received last year from other sources and provide your financial statement if available: All additional funding was provided by Me members of the Santa Clara Valley Audubon Society. In 2019 we created a short video of the pre-COVID Wildlife and Harvest Day celebration to show our members how this festival supports our mission of inspiring people to care about birds and the habitats that support all wildlife. In 2020 we created 50 videos to capture the energy and excitement of the event and a final wrap-up video.To see the videos, please visit: httpsJtyoutu.bs1ISTWg1nLh08.(2019) https:lhvww.youtube.cam/watch?v=KFUxANevlzA&feature=youtu.be(2020) Attachments:Attach your financial statment,and any other helpful information about your project. Program Manager Signature Executive Director Date Signed 02/01/2021 Silicon Valley Audubon Society (Returning) Eligibility Checklist (staff use only). Eligibility YES NO Notes: Be made or sponsored by'a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/project/event Identify how the funds will be used to benefit the Cupertino X community X Organization has previously been awarded funds for the requested purpose(most ; Be awarded only once per project recent funding received FY 2020-21 through Co=urdty Funding Grant) For specific needs,not on going,operational costs X Have more than 75%of the requested funds allocated for direct X service costs versus administrative costs Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only NA submit one application Proceeds generated from the funded activity may only be used for the conducted activity. NA admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved NA by Parks and Recreation Commission City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Community Funding Grant in the past? Yes 0 No It, Yes, when?We were awarded a grant for the current fiscal year Legal Name of West Valley Community Services of Santa Clara County, Inc. Organization: Web Address: www.wvcommunityservices_org Mailing Address: 10104 Vista Drive City: Cupertino Zip: 95014 Phone: President/Executive Josh Selo Title: Executive Director Director: Email: joshs a@wvcommunityservices.org Telephone Number. Contact Person: Sujatha Venkatraman Title: Associate Executive Director Email Address: sujathav@a wvcornmunityservices.orgTelephons Number: 501(c)(3)? * Yes C-) No Year Established 1973 Federal Tax 10 Fiscal Sponsor Name: Fiscal Sponsor Address: City: Zip: Phone: SECTION 3: ORGANIZATlON INFORMATION Total Organization Budget; $3,370,074 Total# of Board Members: 19 Total# of staff; 26 Total# of Volunteers: 300 Mission Statement: To unite the community to fight hunger and homelessness. Brief Description of Organization: West Valley Community Services is a nonprofit organization that has been providing safety net services to low income and homeless individuals and families in the west valley region of Santa Clara County for more than 48 years. Over the last few years, income disparity and housing scarcity have continued to make it difficult for low income and homeless families to live in Silicon Valley. The Silicon Valley Index continues to report that almost 30% of Bay Area residents are unable to afford food and rent. Homelessness has increased by 31% in Santa Clara County in the past 2 years. Housing costs have increased by 13-16% since 2014, while income levels have stagnated for low and middle income workers. As a result, demand for our services has increased exponentially, particularly in light of COVID-19 and the pandemic's disproportionate impact on low income communities and communities of color. Brief Description of Services Provided: WVCS'services are intended to help low-income and homeless individuals and families become self-sufficient by improving accessibility to services and basic needs assistance, and promoting a connection to the community. We achieve this outcome through an array of programs and services: -By providing emergency rental and utility assistance, WVCS is preventing clients from evictions and homelessness.With this help clients are prevented from entering the downward spiral that can make returning to stability difficult or impossible. -By providing food, WVCS is preventing hunger, improving health and nutrition, and enabling clients to spend more of their financial resources an housing, transportation, medical costs, and other life essentials. -By providing case management, information, and referrals. WVCS is helping clients find the resources they need to acquire suitable housing, learn about public benefits, eat more healthfully, cover health care expenses, and much mare. 1.Program/ProjecUevent Name: Gift of Hope Holiday Program 2.Date(s)and/or duration of program/projecUevent(if applicable):December 11,2021 3.Total program/project/event budget $45.000 4.Requested Amount: $10.000 Percent of total program/projectevent budget 220/io S.Program/Project projected income: $0 Percentage of your organization's projected income: 6.Type of Request: OCapUal Improvement 0 Program Support D Event 0 One-time project 0 Other: 7.This grant will fund e(n): 5 Existing program/project/event:established in 2000(year) O New program/projecUevent 8.Describe the purpose of requested funds and the services that will be provided: The December holidays are a challenging time for many people, and especially for families living in poverty. Isolation,stress,and food scarcity stand out starkly at a time when many community members are preparing festive meals, purchasing gifts,or preparing for remote or in person family gatherings. The reality for low Income and homeless families is very different, as families that are struggling on a daily basis in the face of food or housing insecurity are unable to celebrate the holidays,and may not even have enough money to purchase seasonally appropriate clothing for themselves or their children.This reality causes increased stress and mental anguish, which can have long-term cognitive impacts,particularly on young people living in law income families.Gift of Hope was launched many years ago to strike at the heart of these challenges by providing W VCS clients with food, needed household items, and seasonally appropriate clothing during the December holiday season. 9. Please provide a line item breakdown of how the funds will be used in the categories below. If a category is not applicable, put$0: Admin Staff Materials/Equipment $10,00 Entertainment RoomNenue Rental Other Professional Services aOther otal $10100 10. Explain how the request aligns to City mission and values: According to the City of Cupertino's general plan, Cupertino seeks to create a community that is balanced and inclusive for all residents.This program helps realize that vision by serving the needs of our community's low income and homeless residents. 11. Describe haw the progrere/projectlevent fills a community need.Who identified this need?What other similar project/progrem/event exists to serve Cupertino residents? How is your proposed project/progrartJevent unique from similar projectslprograms/events or how do you collaborate to avoid duplication? Over the last few years, income disparity and housing scarcity have continued to make it difficult for low income and homeless families to survive in Silicon Valley. The Silicon Valley Index continues to report that almost 30%of Bay Area residents are unable to afford food and rent. Homelessness has increased by 31%in the past 2 years. Housing costs have increased by 13-16%since 2014, while income levels have stagnated for low and middle income workers. An added complication this past year was COVID-19. which disproportionately impacted low income communities.As an essential business,we operated throughout the pandemic, providing three critical resources food, rental assistance, and rase management, By the end of last year,we had helped more than 4,600 low income and homeless folks, an annual increase of 39%. Gift of Hope provides a seasonal response to the growing demand for help,and there are no other program similar to it that fill this need in Cupertino. 12.Who will be served by this grant? This grant will directly serve 300 low income or homeless Cupertino residents. a)Number of individuals total: 900 b)Number of Cupertino residents: 300 c)Particular community groups: This program serves low income and homeless residents living at or below 250%of the federal poverty line. d)Will the program/projectievenl be available to the entire community/public or are there any eligibility criteria? Yes, this program Is open to the entire community.West Valley Community Services clients will receive food, household items, and seasonally appropriate clothing, and Cupertino residents will be invited to participate as volunteers,to the extent that COVID-19 and social distancing allows.. e)Will there be a charge or fee for the program/project/event(if applicable) There is no charge or fee for this program. f)What outreach methods does your organization use to promote the program/projeGUevent(if applicable)? This event is promoted on our website, in our agency newsletter, in our client newsletter, and on social media. There is also ossify an article about it in The Mercury News/Cupertino Counter. 13. Describe how the funds will be used to benefit or impact the Cupertino community: The Gift of Hope program provides gifts to homeless and low income families living in our service area during the December holiday season. Gifts include traditional items, such as toys and small household appliances,as well as food and seasonally appropriate clothing items that families cannot afford, such as jackets, gloves, hats, and warm sacks. In addition to providing much needed items to families struggling financially, the program allows families living in poverty to preserve household assets for critical household needs Including rent, utilities, and transportation. 14. Demonstrate that the member implementing and managing the program/project/event have adequate experience: The program is overseen by Sujatha Venkatraman, WVCS Associate Executive Director. Sujatha has more than 15 years of nonprofit experience,with a focus on program and policy development, strategic planning,grants and contract management, curriculum development and implementation,and community organization. Sujatha earned her Masters degree In Social Work from the Delhi School of Social Work, and has a Masters in Psychology from the University of West Georgia. Prior to working for West Valley Community Services, Sujatha worked at the Little City Foundation and United Cerebral Palsy of GA/SC. Program implementation Is led by WVCS employees Trishya Movilla and Ann Nguyen under Sujatha's direction. 15. How will success of the program/project/event be measured?: Event success is measured by feedback we receive from clients on our annual client survey. 16. Will more than 75%of the requested funds go towards direct service costs versus administrative costs? O Yes O No 17.Will you collaborate with other organizations to deliver the program/projec7event funded by this grant?If so, which organizations? This program is offered in collaboration with the local faith communities, service organizations,foundations, and corporations. 18. If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants, please describe this support: WVCS is a longtime partner with the City of Cupertino, and has received both Human Services and CBDG grants from the City. 19. Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of program/projectlevent (e.g.fee waivers)? If so,please describe this anticipated support: We do not anticipate receiving any additional financial support from the City of Cupertino for this program. 20. If you are a multi-Judsdictional organization,describe any funding requested from other agencies/organizations in regards to this program/projectmverd request. Indicate whether the funding was granted,denied,or is still pending: We have not applied for funding from other City or Town jurisdictions for this program. Funding provided by the City of Cupertino would be used to support Cupertino residents only. 21. Haw would you fund the program/project/event'rf you do not receive the requested funding?: In order to fund this event,we fundmise from multiple sources throughout the year. SECTION 5: PRIOR FUNDING 1. If you received a Community Funding Grant in prior years,indicate the amounts for each year and describe how those funds were used: We have received the following Community Funding grants from the City of Cupertino: 2019-$20.000-build a shaded structure outside of our pantry to support the needs of WVCS clients and volunteers 2020-$20,000-support the pantry and program space expansion at our once in Cupertino 2. If you received a Community Funding Grant last year: a. Please provide a line Item breakdown of how the Community Funding Grant was used last year in the categories below. If a category is not a22licable, put$0: .Admin Staff i. Materials/E ui ment ii. Entertainment V. Room/Venue Rental .Other Professional Services i. Other Capital $20,00 otal $20,00 b. Who was served by the grant last year? Last years grant served low income and homeless clients coming to WVCS for food or assistance. 1. Number of individuals total: 4,666 ii.Number of Cupertino residents:1,260 III. Particular community groups No particular community groups were served by prior funding. is.Was the programlproject/evenl available to the entire community/public or are there any eligibility criteria? All WVCS programs are available to the entire community,either as clients or volunteers. v.Was there a charge or fee for the program/project/event(if applicable)? There was no charge or fee. vi.What outreach methods did your organization use to promote the program/project/event(g applicable)? This project was promoted in our agency newsletters, in our social media, and in The Mercury News. c.Was the program/projectlevent successful? Please indicate how success was measured: The event was successful-the capital project should be done by the end of April 2021, 3. Please indicate any additional funding received last year from other sources and provide your financial statement if available: This funding was part of an overall capital campaign that we conducted to raise$2.125M to expand our food pantry, program spaces, and build a new mobile food pantry. In addition to the funding from the City of Cupertino,we received funding from Santa Clara County, Kaiser,Sunlight Giving, Bank of America, the MVDAR Foundation, and a variety of individual sources. Attachments:Attach your financial statment, and any other helpful Information about your project. Audit 2019 West Valley CommumN Services FinaLgQ{ Gift of Hoge Program Budgg(gQf Program Manager Signature Executive Director Date Signed 01/15/2021 WEST VALLEY COMMUNITY SERVICES OF SANTA CLARA COUNTY JUNE 30, 2019 . ll i INDEPENDENT AUDITORS' REPORT AND FINANCIAL STATEMENTS i i fE iEI E`f i J E West Valley Community Services of Santa Clara County Independent Auditors' Report and Financial Statements Independent Auditors' Report 1 2 Financial Statements: Statement of Financial Position 3 Statement of Activities 4 Statement of Functional Expenses 5 Statement of Cash Flows 5 Notes to Financial Statements 7 - 19 1 1 i HoOD STRONG LLP n ,: A Century Strong Independent Auditors' Report TO THE BOARD OF DIRECTORS WEST VALLEY COMMUNITY SERVICES OF SANTA CLARA COUNTY Cupertino,California We have audited the accompanying financial statements of WEST VALLEY COMMUNITY SERVICES OF SANTA CLARA COUNTY (the Organization), which comprise the statement of financial position as of June 30, 2019, and the related statements of activities, functional expenses and cash flows for the year then ended,and the related notes to the financial statements. Management's Responsibility for the Financial Statements Management is responsible for the preparation and fair presentation of these financial statements in accordance with accounting principles generally accepted in the United States of America; this includes the design, implementation, and maintenance of internal control relevant to the preparation and fair presentation of financial statements that are free froin material misstatement, whether due to fraud or error. Auditors' Responsibility Our responsibility is to express an opinion on these financial statements based on our audit. We conducted our audit in accordance with auditing standards generally accepted in the United States of America. Those standards require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free from material misstatement. An audit involves performing procedures to obtain audit evidence about the amounts and disclosures in the financial statements. The procedures selected depend on the auditor's judgment, including the assessment of the risks of material misstatement of the financial statements,whether due to fraud or error. In making those risk assessments, the auditor considers internal control relevant to the Organization's preparation and fair presentation of the financial statements in order to design audit procedures that are appropriate in the circumstances,but not for the purpose of expressing an opinion on the effectiveness of the Organization's internal control. Accordingly, we express no such opinion. An audit also includes evaluating the appropriateness of accounting policies used and the reasonableness of significant accounting estimates made by management, as well as evaluating the overall presentation of the financial statements. San Francisco a San dose•San Mateo•Petaluma We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our audit opinion. Opinion In our opinion, the financial statements referred to above present fairly, in all material respects, the financial position of West Valley Community Services of Santa Clara County as of June 30,2019, and the changes in its net assets and its cash flows for the year then ended in accordance with accounting principles generally accepted in the United.States of America. Report on Summarized Comparative Information We have previously audited the Organization's 201.8 financial statements, and we expressed an unmodified audit opinion on those audited financial statements in our report dated January 9, 2019. In our opinion, the summarized comparative information presented herein as of and for the year ended June i 30, 2018, is consistent, in all material respects, with the audited financial statements from which it has been derived. Effect of Adopting New.Accounting Standard As described in Note 2, the Organization adopted the Financial Accounting Standards Board Accounting Standards Update (ASU) 2016-14, Not-For-Profit Entities (Topic 958): Presentation of Financial Statements of Not-for-Profit Entities. Accordingly, the accounting change has been retrospectively applied to prior periods presented with the exception of the omission of certain information as permitted by the ASU. Our opinion is not modified with respect to that matter. San Jose California January 15,2020 2 West Valley Community Services of Santa Clara County Statement of Financial Position -Tune 30, 2019(with comparative totals for 2018) 2019 2018 Assets Cash $ 448,019 $ 569,319 Grants and awards receivable 437,424 491,834 Prepaid expenses 80,658 67,474 Total current assets 966,101 1,128,627 Investments 1,876,865 1,492,314 Prepaid land lease,net 759,590 779,765 Property and equipment,net 3,217,338 3,292,798 Total assets $ 6,819,894 $ 6,693,504 i Liabilities and Net Assets Liabilities: Current portion of long-tern debt $ 11,611 $ 32,569 Accounts payable 30,264 13,226 Accrued compensation 113,202 101,357 Deferred revenue 7,100 9,750 Refundable deposits 24,408 21,643 Total current liabilities 186,585 178,545 j I Accrued interest 198,069 856,453 J Long-term debt,net of current portion 4,016,208 4,111,950 Total liabilities 4,400,862 5,146,948 Net Assets: Without donor restrictions: Undesignated(deficit) 685,129 (63,556) Designated for replacement reserves 307,200 288,000 Total without donor restrictions 992,329 224,444 With donor restrictions 1,426,703 1,322,112 Total net assets 2,419,032 1,546,556 Total liabilities and net assets $ .6,819,894 $ 6,693,504 See accompanying notes to financial statements, 3 West Valley Community Services of Santa Clara County Statement of Activities Year Ended June 30,2019(with comparative totals for 2018) 2019 2018 Without Donor With Donor Restrictions Restrictions Total Total Public Support and Revenue: Government awards $ 1,246,729 $ 1,246,729 $ 1,147,490 Foundation grants 331,453 $ 323,000 654,453 452,248 Contributions 291,676 241,141 532,817 386,045 In-kind contributions 1,648,009 1,648,009 1,571,493 United Way . 60,000 60,000 171,000 Special events,net of direct expense of.$60,437 and$46,550,respectively 182,165 4,000 186,165 181,697 Program fees and rental income 380,422 389,422 353,931 Investment income 64,104 64,104 841111 Forgiveness of debt 671,133 671,133 2000 Net assets released from restrictions 523,550 (523,550) I Total public support and revenue 5,348,241 104,591 5,452,932 4,350,015 Expenses Program services: i Vista Village housing 559,362 559,362 511,685 Affordable housing 3,068 Family assistance 3,465,687 3,465,687 2,853,802 Greenwood Apartments 105,124 105,124 76,999 Total program services 4,130,173 - 4,130,173 _ 3,445,554 l Supporting services: Management and general 188,432 188,432 233,537 Fundraising 261,751 261,751 206,411 Total supporting services 450,183 450,183 439,948 Total expenses 4,580,356 - 4,580,356 3,885,502 Change in Net Assets 767,885 104,591 872,476 464,513 Net Assets,beginning of year. 224,444 1,322,112 1,546,556 1,082,043 Net Assets,end of year $ 992,329 $ 1,426,703 $ 2,419,032 $ 1,546,556 See accompanying notes to financial statements. 4 West Valley Community Services of Santa Clara County Statement of Functional Expenses Year Ended June 36,2019(with comparative totals for 2018) 2019 2018 Vista Family Greenwood Total Management Village Assistance Apartments Program and General Fundraising Total Total Salaries $ 162,257 S 801,936 $ 20,856 $ 985,049 $ 43,114 S 145,332 S 1,173,495 $ 1,060,801 Payroll taxes 15,042 67,243 1,al l 84,096 2,759 12,233 99,088 92,253 Employee.benefits 28,643 127,037 1,348 157,028 23,935 27,194 208,157 152,065 Subtotal salaries and benefits 205,942 996,216 24,015 1,226,173 69,808 194,759 1,480,740 1,305,1I9 Conferences and meetings 45 3,522 7 3,574 12,332 4,448 20,354 15,627 Direct assistance,including in-ldnd of 51,648,009 and 51,571,493,respectively 2,203,412 2,203,412 2,203,412 1,767,367 Dues,fees and other charges 137 9,529 2,674 12,340 3,211 7,611 23,162 19,935 Equipment 3,108 13,601 357 17,066 858 1,984 i9,908 10,531 Insurance 8,501 28,904 37,405 16,971 5,840 60,216 40,318 Interest 9,217 13,259 22,476 22,476 74,557 Maintenance and repairs 19,714 25,062 7,227 52,003 3,045 1,478 56,526 44,376 Outside services 1I,785 43,034 5,136 59,955 55,051 40,134 I55,140 125,558 Postage 354 1,733 46 2,133 1,122 2,241 5,496 3,847 Printing 448 448 1,487 6,142 9,077 13,265 Other expenses 7,945 79,321 1,006 99,272 88,272 67,513 Supplies 455 4,812 61 5,328 9,840 1,524 16,692 31,666 Telephone 1,896. 10,569 I80 12,645 441 1,492 14,578 15,389 Travel 13,795 13,795 2,547 2,094 18,436 9,838 Utilities 39,665 11.359 3,776 54,800 655 2,004. 57,459 43,533 Subtotal before depreciation and amortization 308,764 3,445,317 57,744 3,811,825 177,368 261,751 4-250,944 3,588,439 Depreciation and amortization 250,598 20,370 47,380 318,348 11,064 329,412 297,063 Total expenses as shown on the Statement ofAativities $59,362 3,465,687 '105.124 4,130,173 188,432 261,751 4,580,356 3,885,502 Direct benefit to participants of special events 60,437 60,437 46,550 Total $ 559,362 -S 3,465,687 3 105,124 $ 4,130,173 S 188,432 S 322,188 $ 4,640,793 S 3,932,052 See accompanying notes to financial statements, 5 Nest Valley Community Services of Santa Clara County Statement of Cash Flows Year Ended.Lune 30, 2019(with comparative totals for 2018) 2019 2018 Cash Flows from Operating Activities Change in net assets $ 872,476 $ 464,513 Adjustments to reconcile change in net assets to net cash provided by operating activities: Realized and unrealized gain on investments (26,334) (60,603) Recognition of forgiveness of debt (671,133) (2,000) Amortization of land lease 20,175 . 20,175 Depreciation expense 309,237 276,888 In-ldnd donation of property and equipment (42,965) Change in operating assets and liabilities: Grants and awards receivable .54,410 (122,629) Prepaid expenses (13,184) (36,678) Accounts payable 17,038 (55,795) Accrued compensation 11,845 13,343 Deferred revenue (2,650) (1,975) Refundable deposits 2,765 1,389 Accrued interest 10,750 56,586 Net cash provided by operating activities 585,395 510,249 Cash Flows from Investing Activities: Purchase of investments (452,217) (333,691) Proceeds from sale of investments 94,000 66,997 Property and equipment additions (233,777) (331,602) J Net cash used by investing activities (591,994) (598,296) Cash Flows from Financing Activities Principal payments on long term obligations (114,701) (29,658) Net cash used by investing activities (114,701) (29,658) Net Change in Cash and Cash Equivalents (121,300) (117,705) Cash and Cash Equivalents,beginning of year 569,319 6879'024 Cash and Cash Equivalents,end of year $ 448,019 $ 569,319 Supplemental Disclosures: Cash paid for interest expense $ 8,939 $ 16,334 See accompanying notes to financial statements. 6 West Valley Community Services of Santa Clara County Notes to the Financial Statements Note 1 - Description of the Organization: West Valley Community Services of Santa Clara County(the Organization) is a community- based non-profit health and welfare Organization, incorporated in the state of California in 1976. The Organization's.mission is to unite the community to fight hunger and homelessness and its vision is a community where every person has food on the table and every person has a roof over their bead. E i The Organization owns and operates a twenty-four unit housing complex(Vista Village)and a four-plex(Greenwood Apartments)for low-income families and individuals.The Organization provides a food closet supplied by Second Harvest Food.Bank, local grocery stores, and bakeries for low-income families. The Organization works closely with a variety of local agencies to provide families with information and referral services, to help the emergency needs of lower income families residing within the community and accepts donations that are passed to individuals and families on an as needed basis for emergency assistance. The Organization provides parenting workshops and intensive case management serviees to higher risk families. Note 2- Summary of Significant Accounting Policies: a. .Basis of Accounting The financial statements have been prepared on the accrual basis of accounting in accordance with US generally accepted accounting principles(U.S.GAAP). b. Description of Net Assets Net Assets Without Donor Restrictions—the portion of net assets that are not restricted by donor-imposed stipulations. These net assets are intended for use by management and the Board for general operations. The Board has designated certain net assets without donor restrictions as longterm asset replacement reserves. Net Assets With Donor Restrictions—the portion of net assets that are subject to donor- imposed stipulations. Some donor-imposed stipulations are temporary in nature,the use of which is limited by donor-imposed stipulations that either expire by passage of time or can be fulfilled and removed by actions of the Organization. Some donor-imposed stipulations are permanent in nature, the use of which is limited by donor-imposed stipulations that neither expire by passage of time nor can be removed by actions of the Organization. 7 West Valley Community Services of Santa Clara County Notes to the Financial Statements c. Revenue Reco niiition The Organization recognizes grants and contributions, including unconditional promises to give, as revenue at their fair value in the period the grant or contribution is made. Contributed support that is restricted by the donor is reported as an increase in net assets without donor restrictions if the restriction expires in the reporting period in which the support is recognized. If a donor restriction is not met within the year in which it is received, it is recognized as net assets with donor restrictions. When such restrictions expire,'that is, when a stipulated time restriction ends or a purpose restriction is accomplished,net assets with donor restrictions are reclassified to net assets without donor restrictions and reported as net assets released from restrictions, All other contributed support is recognized as revenue without donor restrictions when received or unconditionally promised. Revenues from government agencies are recognized when the services are rendered and costs incurred. Program fees and rental income are recognized in the period the service is provided. In-kind contributions are recognized at fair market value when donated. In-kind services, which require a specialized skill and which the Organization would have paid for if not contributed,have been recorded at their estimated fair market value as appropriate. d. Cash and Cash Equivalents Cash and cash equivalents consist of cash and money market funds. For purposes of reporting cash flows, the Organization considers all highly liquid investments with a maturity of 90 days or less at the date of purchase to be cash equivalents. e. Grants and Awards Receivable ; Receivables are stated at the amount management expects to collect from outstanding balances. There was no allowance for doubtful accounts as all amounts are deemed fully collectable. f. Investments and Endowment Assets The Organization reports its investments at their fair value.Investment earnings,including realized and unrealized gains and losses, are recorded in the Statement of Activities in the period they occur. Interest and dividend income are recorded when earned. 8 West Valley Community Services of Santa Clara County Notes to the Financial Statements g. Property and Egaipment Purchased property and equipment are stated at cost. Significant donated property and equipment are recorded at their estimated fair value on the date of receipt. Depreciation is computed using the straight-line method over the estimated useful lives of the assets ranging From five to twenty-seven and one half years. The Organization capitalizes property and equipment with a value over$750, h, Deferred Revenue and Refundable Deposits Income received from tenants relating to their last month of occupancy is deferred and recognized in the tenant's last month of occupancy.Refundable deposits represent cleaning deposits received from tenants. i. Fair Value Measurements The Organization classifies its financial instruments ineasured at fair value on a recurring basis based on a fair value hierarchy with three levels of inputs'as described below. Fair value is defined as the price that would be received to sell an asset or paid to transfer a liability in an orderly transaction between market participants at the measurement date.. Level 1 values are based on unadjusted quoted prices in active markets for identical instruments. Level 2 values are based on significant observable market inputs, such as quoted prices for similar instruments or unobservable inputs that are corroborated by market data. Level 3 values are based on unobservable inputs that are not corroborated by market data. The valuation levels are not necessarily an indication of the risk or liquidity j associated with the underlying instrument. j. Functional Expense Allocations Direct costs are charged directly to the applicable program or services, Indirect costs, related to more than one function, are allocated to programs and services by management based on estimates of time spent. k. Income Taxes The Organization is exempt from federal and state income taxes under section 501(c)(3)of the Internal Revenue Code and Section 23701(d) of the California Revenue and Taxation Code. In addition, the Organization has been determined by the Internal Revenue Service not to be a private foundation within the meaning of Section 509(a)of the Internal Revenue Code, 9 Nest Valley Community Services of Santa Clara County Notes to the Financial Statements The Organization evaluates its uncertain tax positions and will recognize a loss contingency when it is probable that a liability has been incurred as of the date of the financial statements and the amount of the loss can be reasonably estimated. Management has concluded that the Organization has taken no uncertain tax positions that would require adjustments to the financial statements. 1. Comparative.Financial Information The financial statements include certain prior year summarized comparative information in total but not by net asset class. Such information does not include sufficient detail to constitute a presentation in conformity with U.S. GAAP. Accordingly, such information should be read in conjunction with the Organization's financial statements for the year ended June 30,2018 from which the summarized information was derived. in. Use of Estimates The preparation of financial statements in conformity with U.S. GAAP requires management to make estimates and assumptions that affect certain reported amounts and disclosures.Accordingly,actual results could differ from those estimates. n. Recent Accounting Pronouncements Adopted In August 20M, the Financial Accounting Standards Board (FASB) issued Accounting Standards Update (ASU) 20t6-14, Not-for-Profit Entities (Topic 958) Presentation of Financial Statements of Not-for-Profit-Entities,which changes presentation and disclosure requirements for nonprofit entities to provide more relevant information about their resources (and the changes in those resources) to donors, granters, creditors, and other users. These include qualitative and quantitative requirements in the following areas: net asset classes,investment return,expenses,and liquidity.This ASU was adopted as of July 1,2018.Accordingly,the accounting change has been retrospectively applied to all periods presented with the exception of the omission of prior year liquidity and availability of resource information as permitted by the ASU. Pronouncement effective in thefuture In June 2018, the FASB issued ASU 2018-08, Clarifying the Scope and the Accounting Guidance for Contributions Received and Contributions Made. This ASU clarifies and improves current guidance about whether a transfer of assets, or the reduction,settlement or cancellation of liabilities, is a contribution or an exchange transaction. It provides a framework for determining whether a contribution is conditional or unconditional,and for distinguishing a donor-imposed condition from a donor-imposed restriction. The ASU is effective for fiscal years beginning after December 15,2018.The Organization is currently evaluating the impact the adoption of this ASU will have on-its financial statements. 10 West Valley Community Services of Santa Clara County . Notes to the Financial StatexmenW . o. Subsequent Events The Organization has evaluated subsequent events from June 30,2019 through January 15, ' 2020, the date these financial statements were available to be issued. There were no material subsequent events that required recognition or additional disclosure in the financial statements. Note 3- Liquidity and Availability of Resources: The Organization's financial assets at June 30, 2019 that are available to meet general expenditures over the next twelve months are as follows: Financial assets: Cash and cash equivalents $ 448,019 Grants and awards receivable 437,424 Investments 1,876,865 Estimated endowment draw 25,000 Total 2,787,308 Less amounts not available to be used within one year: ' Net assets with donor restrictions---purpose restrictions 375,088 Net assets with donor restrictions—endowment, including accumulated earnings 866,615 Client housing deposits 24,408 Board designated replacement reserves 307,200 Financial assets available to meet general expenditures i over the next twelve months $ 1,213,997 The Organization has a goal to maintain financial assets,which consist of cash and short-term investments, on hand to meet 90 days of normal operating expenses, which are, on average, $720,000 (exclusive of in-kind expenses). As of the Statement of Financial Position date,the Organization had approximately 100 days of normal operating expenses available. The Organization has a policy to structure its financial assets to be available as its general expenditures,liabilities,and other obligations come due. II West Valley Community Services of Santa Clara County Notes to the Financial Statements The Organization's endowment fiends consist of a donor-restricted endowment. Annually, when the annual budget is prepared, a dollar amount is established to be transferred from endowment earnings to the general fund. This amount is to be used in support of programs to carry out the Organization's mission. The Organization's endowment funds are also invested with a board designated replacement reserve fund that is designated for building maintenance on all the Organization's property. The Organization has used grants from the City of Cupertino to renovate Vista Village and Greenwood Court Apartments.The use of City funding has limited the use of the board designated endowment funds. Additional funding from the City of Cupertino will be used in the coming 12 months to renovate another Vista Village apartment. Note 4- Investments: Investments at June 30,2019 consist of the following: Cash and money funds $ 23,327 Bond fiords 259,525 Exchange traded funds 569,970 Fixed income 963,291 Equity funds 60,752 Total $ 1,876,865 I At June 30,2019, all investments were measured using level 1 inputs. Note 5- Prepaid Land Lease: The Organization entered into an agreement tp lease land from the Santa Clara County Central Fire Protection District in October 2001.The lease term is 57 years from the date of possession, in exchange for an advanced rental payment of$1,150,000.The lease is amortized on a straight- line basis.For the year ending June 30,2019 amortization is$20,175.At June 30,2019 prepaid land lease of$759,590 is reported net of accumulated amortization expense of$390,410. 12 Nest Valley Community Services of Santa Clara County Notes to the Financial Statements Note 6- Property and Equipment: At June 30,2019 property and equipment consist of the following: Land $ 355,000 Building and improvements 6,206,274 Furniture and fixtures 238,777 Vehicles 204,415 Equipment 140,540 7,145,006 Less accumulated depreciation (3,927,668} $ 3,217,338 Note 7- Long-Term Debt: At June 30,2019 long-term debt consists of the following: Note payable to City of Santa Clara due October 2021, collateralized by real property at Vista Village. Principal and interest payments are deferred for the term of the loan. At the end of the loan,all principal and interest will be forgiven,if a default on the remaining loan conditions has not otherwise occurred. As management does not anticipate a default occurring, each year $2,000 is recognized as a principal payment and a contribution to the Organization. At June 30,2019 there was no accrued interest. $ 4,583 Note payable to City of Cupertino due July 2026, collateralized by real property at the Greenwood Apartments requiring annual payments of principal of$13,836 plus accrued interest at 3.0%. Amortization of the note is calculated on the first $220,000, plus accrued interest from the first five years of the note. A remaining balance of$100,000 is due at the end of the term along with accrued interest thereon. At June 30, 2019,. there was$69,000 of accrued interest. 189,519 Note payable to the Housing Trust due April 2033, collateralized by real property at Vista Village. Principal payments are due each year to the extent Vista Village has surplus cash at the end of each year.The amount due is equal to 10%of the surplus cash. If,at the end of the term loan,an amount is still due,it will be forgiven,if a default on the remaining loan conditions has not otherwise occurred.For the year ended June 30,2019 Vista Village did not have positive cash flow. Interest accrues at 2%per annum. At June 30, 2019, there .was $129,069 included in accrued interest. 341,000 13 West Valley Community Services of Santa Clara County Notes to the Financial Statements Note payable to the County of Santa Clara due August 2033,collateralized by real property at Vista Village. Principal and interest are deferred for the term of the loan. Simple interest accrues at 3.0%per annum. At June 30, 2019,there was no accrued interest. 747,800 Note payable to the County of Santa Clara due December 2034, collateralized by real property at Vista Village. Principal and interest are deferred for the term of the loan. Simple interest accrues at 3.0% per i annum.At June 30,2019,there was no accrued interest.' 220,793 Note payable to the City of Sunnyvale due December 2041, collateralized by real property at Vista Village. Principal is due at the end of the loan and interest is due to the extent Vista Village has positive cash flow.For the year ended June 30, 2019 Vista Village did not have positive cash How. Simple interest accrues at 3.0%per annum.At June 30,2019 there was accrued interest of$53,000, but no amount has been recorded as a liability because the Organization expects all interest to be forgiven. 100,000 Note payable to the City of Cupertino due July 2059,collateralized by real property at Vista Village. Principal payments are due each year to the extent Vista Village has surplus cash at the end of each year.The amount due is equal to 50%of the surplus cash. If, at the end of the term.Ioan,an amount is still due,the loan will be forgiven,if a default on the remaining loan conditions has not otherwise occurred. For the year ended June 30, 2019 Vista Village did not have positive cash flow. At June 30, 2019, there was no accrued interest as this note bears no interest. 2,424,124. 4,027,819 Less current portion _ (11,611) Long-term debt,net of current portion $ 4,016,208 14 West Valley Community Services of Santa Clara County Notes to the Financial Statements Future annual principal payments are as follows: Year Ending June 30, Amount 2020 $ 11,611 2021 11,924 2022 12,247 2023 12,579 2024 12,922 Thereafter 3,966,536 j I Total $ 4,027,819 I • I - I Note S- Board Designated Net Assets: I The Board of Directors has designated a portion of the Organization's net assets without donor restrictions for replacement reserves.Future repairs and replacement costs of Vista Village are set aside in equal amounts of $19,200 annually, as recommended by an engineering study conducted in 2004. The accumulated replacement reserves set aside at June 30, 2019 are $307,200. Management plans .on using the accumulated endowment earnings, should any replacement or repair expenditures arise in the near term. i i I l i 1 15 Vest Valley Community Services of Santa Clara County Notes to the Financial Statements Note 9- Net Assets With Donor Restrictions: At June 30, 2019,the Organization's'net asset with donor restrictions activity is as follows: Purpose Beginnin Additions _ _ Released EndinQ Endowments Endowment earnings $ 309,625 $ 31,707 $ (25,000) $ 316,332 Endowment funds 535,283 15,000 550,283 Total endowment funds 844,908 46,707 (25,000) 866,615 Purpose restrictions Event sponsorship 11,000 4,000 (11,000) 4,000 CARE program 175,000 198,000 (175,000) 198,000 FEP program 15,000 (15,000) Intern program 13,500 (13,500) Equipment acquisition 10,000 5,000 (2,837) 12,163 Education 21,000 21,000 Capital project 118,041 (17,041) 101,000 Special program 27,704 50,393 (39,172) 38,925 Total purpose restrictions 252,204 396,434 (273,550) 375,088 Time restrictions Emergency assistance- time restriction 225,000 185,000 (225,000) 185,000 Total $ 1,322,112 $ 628,141 $ (523,550) $ 1,426,703 Note 10- Endowment.Net Assets: The Organization was the beneficiary of an endowment contribution in 2005, with the donor stipulation that the principal be maintained in perpetuity and earnings used for unrestricted i purposes. The Organization complies with the requirements of the Uniform Prudent ! Management of Institutional Funds Act as enacted by the State of California(UPMIFA). 16 West Valley Community Services of Santa Clara County Notes to the Financial Statements The Board of Directors of the Organization has interpreted UPMIFA as requiring the preservation of fair value as of the original gift date of the donor restricted endowment funds absent any explicit donor stipulations to the contrary. As a result of this interpretation, the Organization classifies as net assets with donor restrictions that are permanent in nature: (a) the original value of gifts donated to the permanent endowment, (b) the original value of subsequent gifts to the permanent endowment, and (c) accumulations to the permanent endowment made in accordance with the direction of the applicable donor gift instrument at the time the accumulation is added to the fund.The portion of the endowment fund that is not classified in net assets with donor restrictions that are permanent in nature is classified as net assets with donor restrictions that are temporary in nature in a manner consistent with the standard of prudence prescribed by UPMIFA and represent accumulated earnings. In accordance with UPMIFA, the Organization considers the following factors in malting a determination to appropriate or accumulate donor restricted endowment funds:(1)the duration and preservation of the various funds, (2) the purposes of the donor restricted endowment funds, (3) general economic conditions, (4) the possible effect of inflation or deflation,(5)the expected total return from income and the appreciation of investments, (6) other resources of the Organization, and(7)the Organization's investment policies. j The Organization's Board of Directors has adopted investment and spending policies for endowment assets that attempt to provide a predictable stream of funding while seeking to maintain the purchasing power of the endowment assets.Under this policy,as approved by the Board of Directors,the endowment assets are invested in a manner that is intended to produce results that exceed the price and yield results of a variety of standard indices while assuming a moderate level of investment risk. The Organization expects its endowment funds to produce a net average annual total return, over the long term, equal to 7%.Actual returns in any given year may vary from this amount. I To satisfy its long-term rate-of-return objectives,the Organization relies on an absolute return strategy in which investment returns are achieved through both capital appreciation (realized and unrealized) and current yield (interest and dividends). The Organization targets a diversified asset allocation that places a greater emphasis on.equity-based investments to achieve its long-term return objectives within prudent risk constraints. The Organization has a policy of appropriating for distribution each year between 2%and 3% of its endowment fund's average fair value; however, the actual distributions may vary depending on various factors, such as endowment performance and the cash flow needs of the Organization. 17 West Valley Community Services of Santa Clara County Notes to the Financial Statements Endowment net assets by restriction as of June 30,2019 areas follows: Permanent in nature $ 550,283 Temporary in nature 316,332 Total $ 866,615 'I Changes in the endowment net assets for the year ended June 30,2019 is as follows: Temporary Permanent Total in Nature in Nature Endowment Endowment net assets,beginning of year $ 309,625 $ 535,283 $ 844,908 Contributions 15,000 15,000 Investment return 31,707 31,707 Appropriation of endowment assets for expenditure (25,000) (25,000) Endowment net assets,end of year $ 3169332 $ 550,283 $ 866,615 Note 11- 'Contributions In-Kind: The Organization has many volunteers that have donated significant amounts of time both for program services and for supporting services. Management estimates approximately 20,600 j hours were contributed by individuals during the year ended June 30, 2019. No amount for this time has been recognized in the accompanying Statement of Activities as'this volunteer time does not meet the criteria required for recognition. The Organization received, and recognized, contributed food inventory in the amount of$1,648,009,for the year ending June 30,2019. I 1 Note 12- Retirement Plan: The Organization has a 403(b)tax-deferred retirement plan for the benefit of employees. The Organization contributes up to 3%of each eligible employee's monthly pay for the year ended June 30,2019. The Organization contributed$19,544 to the plan as of June 30,2019. i I8 West Valley Community Services of Santa Clara County Notes to the Financial Statements Note 13- Concentrations of Risk: Financial instruments which potentially subject the Organization to concentrations of credit risk consist of cash and cash equivalents, grant and awards receivable and investments. The Organization, maintains a majority of its cash in bank deposit accounts that, at times, inay exceed federally insured limits. The Organization has not experienced any losses in such accounts. Management believes the Organization is not exposed to any significant credit risk related to cash. Grant and awards receivables are due from various grantors and government agencies which mitigate the risk associated-therein. Investments are subject to a formal investment policy and monitored regularly. As of June 30, 2019, 66%of grant and award receivables are due from two grantors. For the year ended June 30,2019,94%of the government awards are from three government agencies and 45% of foundation grants are from two foundations. The ability of certain of the Organization's grantors to continue to provide amounts comparable with previous years may be dependent upon future economic conditions and budget constraints. Note 14 a Commitments and Contingencies: The Organization has received funds for specific purposes that are subject to review and audit by the grantor agencies. Amounts received from grantor agencies may be required to be repaid if funds are not used for the purpose for which they were intended. No provisions have been made for any liabilities that may arise from audits by these agencies as management believes it is in compliance with the provisions of the grants. IE E 19 Organization Name West Valley Community Services Project Gift of Hope Expense Type Cost Clothing (jackets, scarves, gloves, pants, shirts, etc) $ 12,000 Toys $ 8,000 Household items, blankets $ 12,000 Food $ 101000 Program supplies (tape, wrapping paper, etc) $ 500 Direct staff $ 21500 ; 1 Total Expenses $ 45,000 . 1 West Valley Community Services (Returning) Eligibility Checklist (staff use only) Eligibility YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/project/event Identify how the funds will be used to benefit the Cupertino community X X Organization has previously been awarded funds for the requested purpose(most Be awarded only once per project recent funding received FY 2019-20 through out of cycle funding) For specific needs,not on going,operational costs X. Have more than 75%of the requested funds allocated for direct X service costs versus administrative costs Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only NA submit one application . . . Proceeds generated from the funded activity may only be used for NA the conducted activity admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved NA by Parks and Recreation Commission City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Community Funding Grant in the past? Yes 0 No If, Yes,when? 2020 Legal Name of Organization: Silicon Valley Jewish Film Festival Web Address: www.svjff.org Mailing-Address: PO BOX 2190 City: Cupertino Zip: 95015 Phone: President/Executive Director: Tzvia Shelef Title: Email: Telephone Number; Contact Person: zvra e e Title: Email Address: tzvia@svjff.org Telephone Number: 501(c)(3)? O Yes D Na Year Established 1991 Federal Tax ID:� Fiscal Sponsor Name: Fiscal Sponsor Address; City: Zip: Phone: .515r:(7n1 Total Organization Budget: $333,000 Total #of Board Members: 14 Total##of staff: 1 Total #of Volunteers: 50 Mission Statement: The Silicon Valley Jewish Film Festival's mission is to reach out, excite and bring together the Silicon Valley community with and through the power of films that showcase Jewish spirit, culture, traditions and humor. We strive to spark a dialogue around entertainment, art, politics, society and global issues. Because it is engaged actively in outreach to different ethnic and religious organizations, SVJFF takes a broad view when it refers to'bringing together the Silicon Valley community.' Brief Description of Organization: The San Jose Jewish Film Series was founded in 1991 by three local residents who recognized the need for high- quality films with Jewish themes in the San Jose metropolitan area. That group later changed its name to the San Jose Jewish Film Festival. In recognition of its evolution into a truly regional entity, the name was changed to the Silicon Valley Jewish Film Festival ("SVJFF"). In 2009, SVJFF became an independent, not-for-profit corporation under Sec. 501(c)(3) of the Internal Revenue Code. Brief Description of Services Provided: What began as a modest annual offering of several films has been transformed into as annual four-week festival held between October and November, In 2020, during this unprecedented time of the Covid-19 pandemic, when many other film festivals canceled their showings, we made it possible for our Bay Area community to participate in the most interactive film festival we have ever had, with the most viewers we have ever had with 21 movies in 15 days, 9659 movie views. 1. Program/Project/Event Name: Silicon Valley Jewish Film Fes 2. Date(s)and/or duration of program/project/event (if applicable):May 19,2021 to June 2, 2021 1 Total program/projectfevent budget: $333,D00 4. Requested Amount: $10,000 Percent of total program/project/evant budget: 3% 5. Program/Project projected income: $333,000 Percentage of your organization's projected income: 3% 6.Type of Request: ❑Capital Improvement ❑Program Support 12 Event 0 One-time project ❑Other. 7.This grant will fund a(n): O Existing program/projecUevent; established in 1991(year) ❑ New program/project/event 8. Describe the purpose of requested funds and the services that will be provided: From its inception, SVJFF was envisioned as a means of bringing high-quality films with Jewish themes to an increasingly diverse metropolitan area, The presentations by SVJFF have consistently addressed the needs of the local Jewish community while, at the some time, connecting with the broader community as a whole. In order to further its commitment to the entire community,the 30th annual SVJFF will have a virtual festival showing approximately 21 movies from May 19 through June 2, 2021..The budget was reduced due to the current COVID 19 pandemic and future donations are unsure. 9. Please provide a line item breakdown of how the funds will be used in the categories below. If a category is not apiplicable, put$0: Adjoin Staff $ Materials/Equipment $ Entertainment $10.00 RoomNenue Rental $0 Other Professional Services $0 Other $0 otal $10.00 10. Explain how the request aligns to City mission and values: We are one of the only Arts 8 Culture organizations In the area for Jewish content and our program serves a large amount of Cupertino residents. 11. Describe how the programlprojectlevenl ills a community need.Who identified this need?What other similar project/program/event exists to serve Cupertino residents? How Is your proposed project/program/event unique from similar project Vprogmms/events or how do you collaborate to avoid duplication? We are the only Jewish festival in the Cupertino area with no duplicating programs.The number of people we reach is continuing to grow each year. 12, Who will be served by this grant? We conduct a survey asking where attendees made and the top three areas are Cupertino. San Jose and Palo Alto. a)Number of Individuals total: 20,000 b)Number of Cupertino residents: 5,000 c)Particular community groups: We serve teens,adults and the elderly. d)Will the program/projectlevenl be available to the entire community/public or are there any eligibility criteria? Yes the program will be available to the entire community/public. e)Will there be a charge or fee for the program/projecVevent(if applicable) Yes,tickets or movie passes are available. f)What outreach methods does your organization use to promote the program/proJect/event(if applicable)? Due to the COVID 19 pandemic we will be using social media and a letter to our existing donors to promote the program. 13. Describe how the funds will be used to benefit or impact the Cupertino community: The funds will be used to bring more directors and actors to the area via online Zoom programs and virtual events. 14. Demonstrate that the member Implementing and managing the program/projectlevent have adequate experience: TZVIA SHELEF(Executive Director): Ms.Shelef joined the SVJFF on a full-time basis in 2011 after an impressive record of excellence in film and television production. Highlights of her background are as follows: (1) Produced 600 television commercials for an international advertising agency. (2)Played a major role in production activity for many American and Israeli films, including production assistance to Steven Spielberg concerning"Schindler's List." (3)Produced major programming for the San Francisco affiliate of the Public Broadcasting System_(4) Managed all aspects of SVJFFs film festivals and its other screenings from 2011 to date.Ms.Shelef has overall management responsibility for all operational aspects of SVJFF, including fundraising, recruitment and supervision of volunteers, and presentation of all film festival activities. 15. How will success of the program/projectlevent be measured?: We see it by the growth of online attendance numbers and end of festival surveys. 16. Will more then 75%of the requested funds go towards direct service costs versus administrative costs? * yes O No 17. Will you collaborate with other organizations to deliver the prograndproject/event funded by this grant? If so, which organizations? We are not collaborating with any other organizations but would be welcome to do so upon request. 18. If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants, please describe this support: No 19. Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of program/project/event(e.g,fee waive If so, please describe this anticipated support: No 20, If you are a multi-jurisdictional organization, describe any funding requested from other agencies/organizations in regards to this program/project/event request. Indicate whether the funding was granted, denied,or is still pending: No 21. How would you fund the program/projectlevent if you do not receive the requested funding?: Donors only. SECTION 5. PRI:),. 1. If you received a Community Funding Grant in prior years,indicate the amounts for each year and describe how those funds were used: $5,000 for 2020 2. If you received a Community Funding Grant last year: a. Please provide a line item breakdown of how the Community Funding Grant was used last year in the categories below. If a category is not applicable.put$0: .Admin Staff $ 1. Materials/E ul ment $ ii. Entertainment $5,00 v, RocmNenue Rental $ . Other Professional Services $ .Other $ Total $5.00 b.Who was served by the grant last year? Our donors and ticket buyers i. Number of individuals total: 20,000 I. Number of Cupertino residents:5,000 iii. Particular community groups We serve teens, adults and the elderly. iv.Was the programlproject/event available to the entire community/public or are there any eligibility criteria? Yes the program will be available to the entire community/public. v.Was there a charge or fee for the progranJproject/event(if applicable)? Yes, tickets or movie passes are available. vi.What outreach methods did your organization use to promote the program/project/event(H applicable)? Due to the COVID 19 pandemic we will be using social media and a letter to our existing donors to promote the Program c.Was the program/project/event successful? Please indicate how success was measured: Ves,we met the challenge of going virtual,which helped us raise the remainder of our budget for the 2020 festival. The festival's audience increased,and our innovative zoom program for viewers,which allowed people to"meet" online to discuss the films,was appreciated by people new to SVJFF as well as long-lime donors. We achieved new numbers in all categories: F 21 movies in 15 days f 9,659 movie views F Average views per movie:460 F 469 pass-holders with all-movie-access F 2,066 tickets purchased (654 unique ticket buyers) Average tickets purchased per movie: 109 8 interviews with directors and guests 21 zoom calls for viewers to discuss the films 3. Please indicate any additional funding received last year from other sources and provide your financial statement if available: The City of San Jose Attachments:Attach your financial statment, and any other helpful Information about your project. Program Manager Signature Executive Director Date Signed 01262021 Silicon Valley Jewish Film Festival (OLD) Eligibility Checklist (staff use only) Eligibility YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/project/event Identify how the funds will be used to benefit the Cupertino X community X Organization has previously been awarded funds for the requested purpose(most Be awarded only once per project recent funding received FY 2020-21 through Community Funding Grant) For specific needs,not on going,operational costs X Have more than 75%of the.requested funds allocated for direct service costs versus administrative costs Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only submit one application NA Proceeds generated from the funded activity may only be used for Based on the information provded in the application,allocation of proceeds the conducted activity generated could not be determend. admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved X Fees will be charged for the requested program/event/project.Approval required by Parks and Recreation Commission from Parks and Recreation Commission. City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Community Funding Grant in the past? Yes 0 N❑ If, Yes, when? 202012021 Legal Name of Organization: Chinese American Coalition for Compassionate Care Web Address: caccc-usa.org Malling Address; City: Cupertino Zip: 95015 Phone: President/Executive Director: Shirley Pan Tide: Director Email: Shirley a@caccc-usa.org Telephone Number: Contact Person: Jeanne Wun Title- Past Board Chair Email Address: jeanne@caccc-usa.org Telephone Number: 11:4: i 10N 7: N0hj-F,F�lI-1'f I"Ir(-)f,,1\-i lo!:j 501(c)(3)? * Yes 0 No Year Established 2007 Federal Tax ID:� Fiscal Sponsor Name: hire a Ameri n Coalition for Compassionate Care Fiscal Sponsor Address: City: Shingle Springs Zip: 95682 Phone: '-)ACTION 3: ORGANIZATION INFORMATION Total Organization Budget: $120.000 Total#of Board Members: 10 Total#of staff: 3 Total#of Volunteers: 150 Mission Statement: Encourage dialogue among Chinese Americans about end-of-life issues so that it is viewed as a natural part of life. Enhance advanced illness and end-of-life care by improving advance care planning and decision-making for Chinese Americans through community outreach education and volunteer, caregiver, and healthcare professional training. Empower Chinese Americans by improving access to end-cf-life resources: producing original Chinese language materials or translating existing materials into Chinese and providing referrals to appropriate organizations. Use a coalition model,where expertise and resources are shared, to ensure Chinese Americans receive exceptional end-of-life care and services that address physical, psychosocial, emotional and spiritual needs. Vision; To build a community where Chinese Americans are able to face the end of life with dignity and respect. Brief Description of Organization: CACCC was formed 12/2005 to address the lack of linguistically and culturally appropriate end-of-life information and training available to the Chinese community and those who serve them. CACCC was incorporated and achieved 501c3 status in 2007. CACCC is the first coalition in the nation devoted to end-of-life care concerns in the Chinese community. An active working coalition of 150 local, state and national partner organizations and approximately 1.500 individual members dedicated to the mission. 10 dedicated volunteer board of directors set policy with 3 part time staff. Prior to COVID. CACCC used facilities of its member partners For training and meetings. Since April 2019, all events are provided virtually. CACCC's focus: helping the Chinese community with advance care planning (ACP)and mindful self-care; providing hospital patient ambassadors (on hold due to COVID); hospice volunteer training: educating Chinese community, and educating healthcare providers who se Brief Description of Services Provided: An overview of the programs, products and services CACCC province to increase awareness and address healthcare disparity at the end-of-life care in the Chinese community. 1.Produce and translate end-nf-life resources and materials from English to Chinese a. DVDs: Loving Life...Understanding Hospice; Kathy& Windy-a documentary film b. Book: Learning to Let Go: Saying Goodbye Peacefully c.Videos: Hospice Care& Palliative Care, Advance Health Care Directive& POLST, Heart to Hearv!)Cards& Heart to Heart®Cafe d. Decision Guides: What is CPR;What is Ventilator;What is Tube Feeding;What is Artificial Hydration e.The Chinese Conversation Starter Kits L End-of Life-Care Glossary 2. Community education and Advance Care Planning outreach 3. Heart to Heart®Cafes 4. Professional healthcare trainings 5.Caregiver and volunteer trainings 6.Weekly Caregiving Stress Reduction Meetings 7.Six(6)-Week Mindful Self- SECTION 4: GRANT REQUESTS 1.ProgrannProject/Event Name: Starting the Conversation and Mindful Self-Care 2.Date(s)and/or duration of program/project/event(if applicable):July 2021 —June 2022 3.Total program/project/event budget: $51.000 4. Requested Amount: $12,000 Percent of total progmm/projectlevent budget: 24% 5. Program/Project projected Income: $0 Percentage of your organization's projected income: 0% 6.Type of Request: ❑Capital Improvement OProgram Support 0Event D One-time project 0 Other: Provide continuity and build on the success of 2020/2021 CFG 7.This grant will fund a(n): 0 Existing program/project/event;established In 2014(year) ❑ New program/projecVevent 8.Describe the purpose of requested funds and the services that will be provided CACCC is hopeful that the City of Cupertino will continue to recognize the value of the programs we provide to the Chinese community. Referencing Mayor Darcy Paul's'gratitude and opportunity theme.where he states how COVID-19 has exacerbated an already vulnerable situation during his January 27 virtual State of the City address, We are grateful for the opportunity to help others. I am proud to represent a city that cares for Its most vulnerable residents: The goal and purpose of requested funds and the services that it will provide is each participant will Obj 1: Understand the importance of having an end-of-life care conversation with family members, loved ones and physicians. Obj 2: Understand the Importance of Advance Care Planning and encourage them to complete an Advance Directive. Obi 3: Learn how to use the Heart to Heart®cards and Chinese Conversation Starter Guides to start the conversation. Obj 4: Reduce stress and learn to practice self-care thro 9. Please provide a line item breakdown of how the funds will be used in the categories below. If a category is not applicable, put$0: Admin Staff $2.50 Materials/Equipment $2.00 Entertainment $ R00 Verue Rental $2,00 Other Professional Services $4,00 WOther increase in printing, mailing,shipping $1,50 otal $12,00 10. Explain how the request aligns to City mission and values: 10. Explain haw the request aligns to City mission and values: Respectfully, we believe CACCC's collaborative model, innovations and signature advance care planning(ACP) programs and initiatives, combined with our mission to build a community where Chinese Americans are able to fare the end of life with dignity and respect is aligned and in the spirit of the City of Cupertino's mission and values to provide exceptional service, encourage all members of the community to take responsibility for one another, and support the values of education. innovation and collaboration. 11, Describe how the program/projectlevent fills a community need.Who identified this need?What other similar project/progranJevent exists to some Cupertino residents? How is your proposed projectlprogram/evert unique from similar projects/programs/events or how do you collaborate to avoid duplication? The ethnic composition of the population of Cupertino, CA is composed of 39,998 Asian residents (66.3%). Chinese Americans are the largest Asian ethnic group. Many Chinese families have poor communication with healthcare providers,often because of language or a lack of cultural competence and discomfort in the Chinese culture when talking about end-of-life issues. CACCC's program uniqueness is that events are conducted,virtually due to the pandemic, in Mandarin with English interpretation,If applicable.Materials are in Chinese. No other dedicated organization is consistent or uniquely qualified on this,sensflive topic or more capable to present and deliver a serious matter with inspiration and humor than CACCC. CACCC will use the best of the best ACP materials to facilitate health and medical care conversations. CACCC is proactively addressing the needs of those who are experiencing anxiety,loss and isolation during COVID through our new mindful self-cam programs 12.Who will be served by this grant? Predominately, the Chinese community of older adults, multgeneraton families,family caregivers and those individuals experiencing anxiety, stress, loss and isolation due to COVID who have internet access capabilities. And due to the nature of providing programs virtually,anyone in the world who has internet access. a)Number of individuals total: 3,450 b)Number of Cupertino residents: 1,035 c)Particular community groups: Chinese community of older adults: multigeneration Chinese American families and family caregivers. d)Will the program/projectlevent be available to the entire community/public or are there any eligibility pinions? Yes, all events and programs are available to entire community/public, however, participant must be bilingual and speak Chinese(Mandarin or Cantonese)to fully benefit from the program. e)Will from be a charge or fee for the program/project/event(if applicable) There is no fee to participate.All programs are no charge. f)What outreach methods does your organization use to promote the prograrNprojectlevent(if applicable)? We will email promotional flyers. press announcement, hold virtual or phone press conferences, if applicable, and secure radio and TV interviews.We will promote and post event information and schedule on CACCC website, Facebook and Evenibrite, as well as send e-newsletter and cross promote with other organizations like Alzheimer's Association, El Camino Hospital's Chinese Health Initiative and AACL Media coverage examples visit: hftp://www.caccc-usa.urglentarchive.htmi 13. Describe how the funds will be used to benefit or impact the Cupertino community: Funds would enable CACCC to continue to conduct a series of virtual events targeting the Chinese community and when safe,we will adapt to the COVID protocols and incorporate face to face events at Cupertino Senior Center and Cupertino Library: until then, programs will be conducted virtually. Programs include. Heart to Hearl®Cafes; ACP presentations and AI-CD workshops, presentations on Understand Hospice 8 Palliative Cares; How to Start the Conversation with Your Family; host new guest lecture series. Taboo Talks by leading healthcare professionals in their field of expertise, conduct weekly Mindful Caregiver Stress Reduction meetings and Mindful Self-Care Workshops.The impact on Cupertino residents would be invaluable as it will benefit them directly by their event participation.They would be positively impacted by the engagement and the process of starting the end-of-life conversations with family members, caregivers and their physicians regarding their end-of-life care wishes. 14. Demonstrate that the member implementing and managing the program/project/event have adequate experience: Shirley Pan, Director of CACCC, has been with CACCC since 2016. She has a successful track record of managing and implementing, as well as overseeing many community events and projects.CACCC has a dedicated and trained group of volunteers that provide event and program support. Some community events include: 2016- 'Kathy &Windy'Premieres and Panel Discussions 2017- 'Saying Goodbye With Love'Essay Contest, 30-Hour Hospice&Palliative Care Volunteer Training 2018- CACCC 12th Anniversary Fundraising, When East Meets West Professional Forums 2019- Managed and coordinated Reimagine San Francisco; 'Starting the Conversation' Project, and Professional Healthcare Forums. 2020— 'Compassion in Action:A Year to be Mindful"CACCC 15 Year Celebration events 15. How will success of the program/project/event be measured?: Each participant completes an evaluation survey poll or forth at the conclusion of the programs. The goal is to achieve an overall participation satisfaction of 80%. 16.Will more than 75%of the requested funds go towards direct service costs versus administrative costs? O Yes O No IT Will you collaborate with other organizations to deliver the program/project/event funded by this grant? If so, which organizations? CACCC endeavors to collaborate with other organizations and individuals whenever and wherever it is appropriate. In 2021,we will leverage the month of November as it is National Hospice and Palliative Care Month and National Family Caregivers Month for education and outreach and in 2022,we will leverage National Healthcare Decisions Day(April 16)to promote advance rare Conversations and planning. 18.If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants,please describe this support: No,we have not received in-kind support from the City of Cupertino. 19. Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino Call of Community Funding Grants for this type of program/projectlevent(e.g.fee waivers)? If so, please describe this anticipated support: No,we do not anticipate receiving additional financial or in-kind support from the City of Cupertino. 21 If you are a mull-jurisdictional organization,describe any funding requested from other agencies/organizatons in regards to this program/project/event request. Indicate whether the funding was granted, denied,or is still pending: No, not applicable. 21.How would you fund the program/projectmvent if you do not receive the requested funding?: CACCC will continue to seek funding or scale back on some of the events, or modify the program, accordingly, or may not do them at all. SECTION 5: PRIOR FUNDING 1. If you received a Community Funding Grant in prior years, indicate the amounts for each year and describe how those funds ware used: CACCC was honored to receive our fast Community Funding Grant in 2020/2021. Currently, we are in the second half of our grant period: however, we have 6 months of data from which to provide our best estimate. We will continue to conduct virtual ACP activities; provide weekly Mindful Caregivers Stress Reduction meetings; Mindful Self-Care Workshops and introduce a new guest lecture series:Taboo Talks by leading Chinese healthcare professionals in their field. 2. If you received a Community Funding Grant last year: a. Please provide a line item breakdown of how the Community Funding Grant was used last year in the categories below. If a category is not applicable, put$0t .Admin Staff $1,50 ii. Materials/E ui ment $1,50 iii. Entertainment $ v. RoomNenue Rental $ . Other Professional Services $2,00 A. Other printing. mailing, shipling $1,00 Total $6,00 b.Who was served by the grant last year? Chinese community; Chinese Americans: older adults and multigeneration families, caregivers and those individuals who are experiencing anxiety, loss and isolation during this global pandemic. I. Number of individuals total: 3,031 ii. Number of Cupertino residents:909 iii.Particular community groups Chinese community; Chinese Americans: older adults and multlgeneration families,caregivers and those individuals who are experiencing anxiety, lass and isolation during this global pandemic. iv.Was the program/projectfevent available to the entire community/public or are there any eligibility criteria? All programs were free and available to the public; however,our primary focus targeted the Chinese community, bilingual,older adults, multi-generation Chinese Americans,families and caregivers. v.Was there a charge or fee for the programlprojectfevent(if applicable)? There was no change or fee for our programs and events. vi.What outreach methods did your organization use to promote the programlproject/event(if applicable)? CACCC used social media and news media: print. broadcast: radio and TV, online, as well as a-list distribution; website, Facebook, Linkedln,Twitter. c.Was the program/project/event successful? Please Indicate how success was measured: 1.Through pollslsurieys: Receive 99%overall satisfaction rating from event evaluations and 99%of participants indicated they would recommend CACCC events to others 2. From the Heart to Heart Cafe Evaluations, respondents reported:a. They had a joyful experience in a HTH We. b.They were able to say what their end-of-life wishes at the event.c. The Heart to Heart Cafe made It easier for them to talk about death. 3. Participant comments include: Learned about hospice care and I can have better preparation of last period of my life; Please provide more workshop about the end[af-life communication; Open my heart and mind to discuss the topic about death with strangers; We can talk openly and honestly; Very professional meeting and benefit a lot 3. Please indicate any additional funding received last year from other sources and provide your financial statement if available: In 2020, CACCC received the fallowing income from: (financial statement is not attached) Heart to Heart®Card sales:$11,011 Grants:$39,780 Donations:$53,312 Sponsorships:$43,500 Attachments: Attach your financial statment, and any other helpful information about your project. 26143237982608522 ] 1 443027435703 7.202020Tef 19990300282608522 7 7332 21 443027435703.7. 2.2 .ptlf Program Manager Signature CACCC Past Hoard Chair Date Signed 02101/2021 https://www.singtaousa wm/sf/446-%E7%81%A3%ES%8D%80/`2948450-%ES%AA%BD%E8%AD%9B%ES %AE%89%E5%AF%A7%E5%BA%A7%E8%AB%87%E5%91%A8%E5%85%AD%E7%B7%9A%E4%B8%8A%E7 %999uBB%E5%A(l ampw8 19 Sil I I I L I w a T fP Understanding Hospice & Palliative Care $ RSVP '2173aaa' don c Tns • f+P,1:T V N)*Fj? What are Hospice&Palliative Care? • Spni-01EP3a? Howtorequasttheservices? ■ • *Msixxmn7,1p 119u? Are hospice and palliative care covered by insurance? � • • 'f �qung1� xT4? What are the benefits to patients and families? • ;pIBTU4#f#Tt&WM? What is the role of volunteer in hospice care? July 25, 2020, 10:00 - 11:30 AM (PT) by Zoom Meeting ■ 00 Sophia Chan Carrie Chan Carrie Huang lingYi Lee Kwai Chun Chan P1111WISE33WARfUK *114P9 *T*3& Event is conducted In Mandarin 01404,41L CITY OF Scan QR Code or call to CUPERTINO Register: 866-661-5687 r Al 25 Bliyfi '-,,p r 4Ud€�-0ls'fazPv tax` '.F '�';4 %s`2'R8 • M:� l� . rl;��`NOpM K: 7 fl 25 F ( Rai ) � 10 �$ � 1 1 �$" ' T7 nc t . A,J�Q A i ,Al±mERApxII, Zoomf]tl: https://zoom.us/j/81885256956 4.06 M (www.caccc-usa.org)#R:g ° 'l IC Hill- WEr, r ' ��t+r��iy�� II�R ( Cu��pgqe//��rtino ) ��7TR Lb ' M XT� t**J\ t ptl.` Tn ��r�nCAhTMMM75ua� 0 ,0" R�7LIA5n,—R0 ]n \MP3 � ' 3 3 TAMEflR Ft"h 1 ON N I . I i httns://www.world iournal.com/7058412/art lcle-%E8%M%SD%ES%AD%98%ES%AE%89%ES%AF%A7%E 7%85% 7%Ee%AD%B7-%E7%BE%SE%E8%SF%AF%E6%85%88%ES%BF%83%E7%B7%9A%E4%B8%8A%E 5%BA%A7%EB%AB%87/?ref=%E5%A4%A7%E9%A6%96%E9%AO%81 %ES%88%8A%E9%87%91%E5%81 %B1 YjwOr dold Journal stm W Y'fYTAG RII:T rL�lidJtlta`JC oZ!,4E-*O/ r It 2020�.07 A 22 a 06:00 �W 7 A 25 H ( R9 Sao z6KI j&f-0 � gg �;��T • 3f�3kn#tC�1RFz�i.� d9�'��rS�i1�n0 • �il� Fv�,uk��1& fJ rmn� �r F mnonah1 ( ��m 9MMIR �� 7 Q n = min • 25 aa� ® 30 33 • Zoom Meeting: https:/Izoom.us/j/81885256956 Chinese American Coalition for Compasionate Care (CACCC) (OLD) Eligibility Checklist (staff use only) Eisribil_'ty YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/project/event Identify how the funds will be used to benefit the Cupertino X communi X Organization has previously been awarded fonds for the requested purpose(most Be awarded only once per project recent funding received FY 2020-21 through Community Funding Grant) Information provided did not identify specific funding allocations and/or funding For specific needs,not on goin&operational costs X was designated for ongoing operational costs. Have more than 75%of the requested funds allocated for direct X 26%or more of the requested funds were allocated toward expenses not directly service costs versus administrative costs tied to the proposed program/event/project(i.e.:organizational staffing costs) re Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only NA submit one application Proceeds generated from the funded activity may only be used for NA the conducted activity admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and approved NA by Parks and Recreation Commission City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Community Funding Grant in the past? Yes 0 No If, Yesr when' 2020 Legal Narne of Organization; Rotary Club Of Cupertino Web Address.- Mailing Address: PC Box 237 City: Cupertino Zip: 95015 Phone: Presidentfl=xecutive Director:Sivari Rosenber Title: President Email: Telephone Number: Contact Person: rrinPaone Title. Fund development Director Email Address: Telephone Number: 501(c)(3)? Yes 0 No Year Established 1992 Federal Tax ID:— Fiscal Sponsor Name: Cupertino Rotary Endowmenri Foundation Fiscal Sponsor Address: Pa Box 1101 City: Cupertino Zip: 95015 Phone: Total Organization Budget: $200,000 Total #of Board Members: 14 Total#of staff; fl Total #of Volunteers: 210 Mission Statement: Rotary International Mission Statement'Together, we see a world where people unite and take action to create lasting change —across the globe, in our communities, and in ourselves." Brief Description of Organization: Cupertino Rotary is a non-profit Club that is part of Rotary International, a worldwide organization with 1.2 million members in over 200 countries and regions. Cupertino Rotary fundraising is important to our core outreach projects, but more than that, we focus on hands-on projects that connect us directly with those in need. Our members volunteer over 12,000 hours yearly working to make our community a better place. Cupertino Rotary's members broadly reflect the rich ethnic fabric of our community and come from various sectors, including the leaders of our local and corporate businesses, schools, city staff, and non-profit community organizations. Through projects large and small,we are dedicated to improving the quality of life for people in our community. Brief Description of Services Provided: COMMUNITY SERVICE- Last year, more than 1,000 hours of volunteer work and over $42,000 were devoted to over 20 projects that delivered turkey and trimmings to more than 150 community residents; connected Ngh school students with veterans for video interviews; and twice assembled over 50 volunteers to make individual homes safer and healthier for low income seniors. We also helped many local nonprofits expand their Covid related services to the community. YOUTH SERVICE- Youth Service programs build confidence, self-esteem, and leadership skills. We support the youth of our community through student art exhibits, and robotics competitions, as well as Kids Shopping Day, a youth poetry contest, Safe Routes to Schools, and Dr. Seuss Reading Day. VOCATIONAL SERVICE-Vocational Services enables our Rotary Club to be a driving force for individual success by supporting Career Technical Education Workforce Development, education grants to teachers. GED program support, and student schola SECTION 4: GRANT REQUESTS 1. PrograMPniject/Event Name: Cupertino Fall Festival 2. Date(s)and/or duration of program/projectlevent(if applicable):Sept 11,2021 3.Total program/project/event budget: $65,000 4. Requested Amount: $12,000 Percent of total program/project/event budget: 18% 5. Program/Project projected income: $6 Percentage of your organiwiion's projected income:0% 6.Type of Request: OCapital Improvement 0 Program Support DEvent 0One-time project DOther: 7. This grant will fund a(n): I12 Existing prograndprojectlevent: established in 2005(year) ❑ New program/project/event 8. Describe the purpose of requested funds and the services that will be provided: Beside the projects above, Rotary provides direct services to the City as follows: 1)Years ago the City held a separate Health and Safety Fair. It entailed significant City employee participation to execute. In 2005, the decision was made to incorporate it into the Fall Festival to reduce the need for City resources.The City provided $5000 i0 offset Rotary's costs. 2)The City presents an Earth Day festival every April,with significant resources provided by City employees.Years ago,the Environmental Resources team decided to partner with Rotary to support a second environmental event. The"Earth Zone" at the Fall Festival meets this need. Again the City provided $5000 to offset costs. 9. Please provide a line item breakdown of how the funds will be used in the categories below. If a category is not Io licable ut$0:Admin Staff $0Matertals/E ui ment $12000Entertainment $0RoomNenue Rental $ Other Professional Services $ Other $tal $12,00 10. Explain how the request aligns to City mission and values: See 8 above for a few specific details, but the Fall Festival aligns with the City's Public Safety programs, Environmental Programs, Youth Programs, Diversity initiatives,and general Community engagement. Please also note, in the event that the traditional Fall Festival cannot be held,we will investigate alternative delivery options for these programs. In any case the need for the funds is actually increased, so the sponsorships continue to add the charitable funds available to meet that increased need. 11.Describe how the program/project/event fills a community need.Who Identified this need?What other similar project/program/event exists to serve Cupertino residents? How is your proposed projecilprogram/event unique from similar projects/programs/events or how do you collaborate to avoid duplication? Cupertino Rotary has been producing community festivals in Cupertino for over 40 years, beginning with an annual Oktoberfest.As Cupertino changed, the festival changed, morphing Into the Golden Jubilee, celebrating Cupertino's 50th birthday, and finally the Fall Festival. Throughout,we have worked with other organlzatiens, Including the following current partners: City of Cupertino as outlined above. Bath Cupertino School Districts,for seminars, an shows, robotics displays, etc. The World Journal,for joint promotional and vendor opportunities. The Cupertino Library Foundation 12.Who will be served by this grant? Every dollar raised at the Fall Festival goes directly toward funding Cupertino Rotary's charitable projects in the local community. We do over 50 projects right here in the community every year. a)Number of individuals total: 800 b)Number of Cupertino residents: 500 c)Particular community groups: We partner with and support the following organizations:West Valley Community Services,the Northwest Y,Via Rehabilitation Services, Live Oak Adult Day Care, and many others. d)Will the program/project/evenl be available to the entire community/public or are there any eligibility tritons? All services are available to the entire community. e)Will there be a charge or fee for the program/project/event(if applicable) No charge f)What outreach methods does your organization use to promote the program/projectlevent(if applicable)? The event is promoted through social media, a program insert in the Courier, Byers to the school population, and highlights in the Cupertino Scene. Banners are also used. 13. Describe how the funds will be used to benefit or impact the Cupertino community: See description of services provided and answer to Question 8 above. 14, Demonstrate that the member implementing and managing the program/projectmvent have adequate experience: We have been a leader in working with City staff to present Festivals that minimize impact to the neighbors while providing educational and entertaining content to the attendees, with a 40 year track record. 15. How will success of the program/project/event be measured?: Number of attendees,and feedback from vendors.We will also do a survey this year. 16.Will more than 75%of the requested funds go towards direct service costs versus administrative costs? ® Yes O No 17.Will you collaborate with other organizations to deliver the prograMprojecVevent funded by this grant? If so, which organizations? City of Cupertino Cupertino Union School District Fremont Union High School District De Anza College Fine Arts League of Cupertino The World Journal newspaper 18. If your organization has ever received financial or in-kind support from the City of Cupertino outside of Community Funding Grants, please describe this support: Fee waivers for Memorial Park 19. Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of program/project/event(e.g.fee waivers)? If so, please describe this anticipated support: Fee waivers for Memorial Park 20, If you are a multi-junsdictional organization,describe any funding requested from other agencies/organizations in regards to this program/project/event request. Indicate whether the funding was granted, denied, or is still pending: None 21.How would you fund the program/projecVevent if you do not receive the requested funding?: Our net proceeds would be directly affected, reducing the number and size of charitable projects that we would be able to do in the future. In addition,we would not be able to support the City's Health and Safely Fair and Environmental Fair activities at the same level. SECTION 5: PRIOR FUNDING 1. If you received a Community Funding Grant in prior years, indicate the amounts for each year and describe how those funds were used: $12,000 for each of the last four years,$10.000 per year for the previous 10 years 2. If you received a Community Funding Grant last year: a. Please provide a line item breakdown of how the Community Funding Grant was used last year in the categories below. If a category is not applicable, put$0: .Admin Staff $ 1. Materials/E ui ment $2,50 ii. Entertainment v. Room/Venue Rental . Other Professional Services i. Other Mail, for service projects $9,50 Total $12,00 b.Who was served by the grant last yei We partnered with and supported the following organizations: West Valley Community Services. Our Daily Bread, Home First Services, Uplift Services, JW House, and many others. J. Number of individuals total: 1,000 li. Number of Cupertino residents:500 iii.Particular community groups Through our partnership with the World Journal the event has an increased focus on the Chinese American community, although the services are available to all impacted groups. is,Was the program/projecUevent available to the entire community/public or are there any eligibility criteria? Available to the entire community v.Was there a charge or fee for the program/projecIfevent(if applicable)? No charge. vi.What outreach methods did your organization use to promote the program/project/event(if applicable)? Primarily an 8 page insert in the Cupertino Courier. c.Was the program/project/event successful? Please indicate how success was measured: Yes,thanks to our various sponsors, including the City of Cupertino,we were able to maintain our services to those in need in the community. Many of the projects, were targeted to Covid relief efforts. See attached program book highlighting the services provided by the virtual 'Festival'funding 3. Please indicate any additional funding received last year from other sources and provide your financial statement if available: Funding for the Rotary Club chartable projects typically comes from four key sources.Our fundraising events: Fall Festival,Golf Tournament, Crab Feed, and Global Elegance Dinner-generate revenue from attendees. Secondly, these events count on significant contributions from our corporate and individual sponsors.A third source of funds are matching funds from The Rotary Foundation. Our Rotarians donate to The Rotary Foundation (TRF)each year and while some of this money is used to fund global projects such as polio eradication, much comes back to the club as matching funding for our own international projects. Lastly, distributions from the CREF Permanent Fund, our own Endowment Foundation,contribute significantly to our charitable work. Sources of Funds: $230,000 Fall Festival,$35,000 Golf Tournament, $50,000 International Matching Funds, $52,000 Global Elegance, $24 000 CREF Endowment Distribution,$60,000 Misc,$12,000 Attachments:Attach your financial statment, and any other helpful information about your project. Fall Festival booklet 2020-Final.pdf Program Manager Signature Fund Development Coordinator Date Signed 02/01/2021 41, Rotary ON,Club of Cupertino FALL FESTIVAL • RECOGNITION PROGRAM a MAKE IT AN AMAZING VISIT Our amenity rich community is thriving with shopping and services, dining, drinks and specialty treats, fun events for the family and a Residence Inn hotel for stayover guests. It's all here waiting for you to make great things happen. Find something you love. AT&T Bahaps Cuts&Color Capezio Golden Vision Howard's Shoes Meriwest Credit Union Target Enlightened burgers, craft beer, artisan pizza and more. Alexander's Patisserie Alexander's Steakhouse 850c Bakery Cafe Eureka! Gentry Bar&Restaurant Hai Di Lao Ippudo Lazy Dog Mee Fresh Myungrang Hot Dog Oren's Hummus Pacific Catch Pasta Armelllno Philz Coffee Pineapple Thai Pressed luicery Rootstock SomiSomi Sul&Beans Tea Chansii MAINIt, CUPERTINO $p sne wu�R.M e�R-v nAen Located on Rarvm Croce Mehn,d ea.zeu Wdla Rand and Gm..Aeawe mm�ree,c.gnn o.corn Fall Festival 2020 Recognition Program For the Past 40 years, the Rotary Club of Cupertino has organized an Autumn Community celebration in Memorial Park Originally designed as an Oktoluede n,this event evolved over the years into a Fall Festival that brings together Cupertino's diverse cultures in a day of celebration and enjoyment while providing opportunities to learn and participate in many fun,educative, and Inspirational activities.In partnership with the City of Cupertino,we have enjoyed organizing this community,family,mltural, and educational event that camas to everyone. The event is also a major hardener for the yearly charitable projects of the Rotary Club. Stuart Romnbarg In response to Covld-19, the City and County have canceled all large Fewrdmt outdoor gatherings to promote social distancing, and consistent with Rotary Club of Cupertino keeping our community sale, Rotary will not be holding the event this year However, we do want to thank all our corporate spons rs for their continued support of our Community protests and highlight same of the products that their sponsorship has made possible. Thank you! Stay Safe!! See you next year! THANK YOU TO ALL OF OUR COMMUNITY p�PARTNERS 00 Y MAIM that eueeaiixo NTURBAN NENRs a�ly' �te. Graystone Consulting_ Seek,Hici Paoesxrz Coupnw J= SAN 105E WATER COMPANY �.. -Chargepoinr. SAFEWAYOT—'"T--"-17 nireteen ryry��yyyy �- .. caP IN!-'RTINO M%fRwas ...m... UIn..1P1.. 3ami6 MAIN!-' �ell d",.,,,�„.u� P;r Recalgy �;/naAx aFiEaGv PROTECTIVE MASK DISTRIBUTION: CUPERTINO ROTARY Thanks to a Rotary Club to Rotary Club Service Above Self connection formed years age, the - - - '- Kaohsiung West Rotary Club of Taiwan EIYARRAMNONIT Rotary is a network of 1.2 million neighbors, friends, obtained 4,000 masks and donated "--- leaders, and problem solverswho see a word where them to the Cupertino Emery Club. people target and take action be create lasting change- These protective masks were delivered in our communities and across the globe. to Sunnyview Retirement Community, CuperOrro Union School Chloride,Fremont Fundraising supports our core outreach projects and Union High School District, El Camino the Covid-19 epidemic has upended our traditional Hospital,Good samaritan Hospital,and fundreisin activities. Cupertino Rota II the Santa Clara time Shen p rsoAca g p supported is espust y early iApril.equi a time when personal thankful to our dedicatedueonsorswhoeranJc us this pmteeiva equipment was in short supply yea worenabllg ing tim a toe continue unpecedentednerand charitable nacionwlde. work during a time of unprecedented need. Lai HOSMAL SUPPUES FOR ECUADOR: In partnership,the Cupertino,T ebama COVID Projects (Ecuador, and Edmonton (Canada) Riverview Rotary Clubs raised over Cupertino Rotary quickly responded to unexpected local and Sil for hospital supplies disaster international community needs,as outlined below: relief,providing critically needed COMD related PPE and equipment to three MAJOR GRANT PROGRAM: public hospitals in Cuenca and Machab Ecuador. To support agencies working to allay economic hardship caused by the COVIOI9 Pandemic,six local non-preHt groups aimed at serving QUILTS FOR XUDS MASK D6 IRDIION: homeless individuals and struggling families-Horm irB Services,Our Daily Bread,Wen Valley Community Services,MCA,Women's Shelter, Our industrious'Quilts for Kids' sewing Uplift Services,and gW House- recelved E12,Minfunding. neampivotedtomaking tlmhmasksfor .� munirymemorm. Theares"land Inaddnion,Cupemno Rotarydonate nduolmeract Clubsinsuppott cheerful masks filled a void early in our ofthelr"Senior Pen pals,' proles,a servioeopportunityfor high school shaker in place effort as our community sedwas to white care letters,am ails,&cards to naming home residents members sought masks while saving and hospice patients during the COVID-19 quarantine. medical PPE equipment for our fire line responders. manWOLFS ROAD HYGIENE PROIEtt:Cupertino Rotzdampackagedand deliveridUrstaid kits, hygiene his and bait necessities to homeless individuals currently camped along Wolk Road in an effort as limit their Covid-19 exposure. 132W CDPERNNO TOGETHER-DONNIE A LUNCH KARMA BIKES REPAIR CLINIC: Because our weekly lunch meetings Files have increased In - - ///�� now take place via Zoom, In lieu of popularity as an estimate buying lunch,Cupertino permits have means of transportation =sir contributed to the Cupertino Chamber a our Covid-19 of Commerce Cupertino Together - induced social distancing. Ornate a Lunch Program which hires In parmershlp with Karma local restaurants and caterers to prepare bikes, Cupertino Roory �..�. meals for families in need, supporting sponaored and supponed ... both families and businesses adversely a hake repair clinic for A- effected by pandemic. risk d:ildren and adults. REWILDING TOGETHER: THANKSGIVING MEAL DISTRIBUTION: Complying with stria — -- - - -l" \ -!I _ Each year on Thanksgiving morning, Cu Covdl9p t t - _ \ y pertino Rrtar ens Of ammntee s emitted the a��mar ��t delver compete, fully Prepared senator of theh fa —! �v~ Thanksgiving meals co families neighbor in d IY help ivd� deamadermadbyloralcrmmumly and pedo d y 1 I ✓ _ — — service agencies and schools. outside cleanup by � .v — Rene ems may be unemployed, trimming plants,removing infirm,elderly,in temporary shelter, a damaged planter box, or otherwise incapacitated. Each meal includes a 10 to 12 pound and eliminating general _ turkey,mashed potatoes,gravy,mnbeny sauce,and Hawaiian rolls all clutter. fully cooked,and serves 6 to 8 people. BACK TO SCHOOL BACKPACKS: This year, 60 socially distanced volunteers will deliver 120 meals. Volunteers will avwe a Me Safeway parking ioe,meals w!ll be placed Although students are currently homing In their bunk or bad seat far delivery to M.arranged deninations. remotely,the need for school supplies and Gobble,Gabble! clothing hasn't estimated. The Henry and West Valley Communsy Services sponsored 'back to school' shopping day of previous years, was replaced with Cupertino Rotary§ members broadly reflect the fich delivery of backpacks containing needed ethnic fabric of our community and come from various supplies and dolling directly to students sectors including the leaders of our local and corporate in need. businesses, schools, city staff, and nonprofit community organizations. Gas ANZA FOOD GIFT CARDS: Provided 82000 to De Mrs The dub meets every Wednesday at now for a lunch College to punchase emergency program and guest speaker(currently via Zoom). To learn grocery store food gift cards for ore visit our wehsim atwwwcupertinomtaryorg. students struggling with housing and food Insecurity,due m pandemic related job loss. 91 ARMSTRONG RETIREMENT PLANNING, LLC Adana,CFP•, MRA.MSFP BobBobAdams, l Planner Wact tionser MSF Always here for you. Questions ahou[yourportfollo? or when you mn retire? Looking for o Fee.ORIV advisor? 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Save money and make an impact WERE A LL I N THIS TOGETH EA. in your community. visit: SVCNBanEnergy.org/exub CLEANENERGY thrive Rotary Club of Cupertino (Returning) Eligibility Checklist (staff use only) Eli 'bg�ila'fy YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/project/event- Identify how the funds will be used to benefit the Cupertino X community X Organization has previously been awarded funds for the requested purpose(most Be awarded only once per project recent funding received FY 2020-21 through Community Funding Grant) For specific needs,not on going,operational costs X Have more than 75%of the requested funds allocated for direct service costs versus administrative costs Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only NA submit one application Proceeds generated from the funded activity may only be used for the conducted activity NA admission to or participation in the event.must be"free of charge"to Cupertino residents unless stated in the application and approved NA by Parks and Recreation Commission City of Cupertino Fiscal Year 2021 Community Funding Grant Application Have you ever received a City of Cupertino Community Funding Grant in the past? Of Yes 0 No If, Yes,when?2020-21+ Legal Name of Organization: Euphrat Museum Of Art Web Address: www_deanza,edufeuphrat Mailing Address: 21250 Stevens Creels Blvd., Oe Anna College City: Cupertino Zip: 95014 Phone: Preside ntlExecu ti ve Director: Diana Argabrite Title: Director Email: argabritediana@fhda.edu Telephone Number: Contact Person: same Title: same Finail Address: same Telephone Number: same SECTION 2: NON-PROF1 i 501(c)(3)? 4 Yes 0 No Year Established 1970 Federal Tax ID: Fiscsl Sponsor Name: Foothill De Anza College District Fiscal Sponsor Address: 12345 El Monte Road City: Los Altos Hills Zip:94022 Phone, ECTION 3: ORGANIZATION INFORMATION Total Organization Budget: $132,700 Total#of Board Members: 6 Total#of staff: 2 Total#of Volunteers 4 Mission Statement: The Euphrat Museum of Arts mission is to research, produce and present challenging exhibitions and educatiarial material that provide a resource of visual ideas and a platform for communications. Our exhibitions and programs highlight our heritage of different cultures; enhance understanding of art fundamentals,art history, and esthetics; and augment college instruction. Brief Description of Organization: The Museum traditionally presents one of a kind exhibitions, events,and programs that reflect the rich diverse heritage of our area. Our award winning Arts&Schools Program joins professional artists and students of all ages in using art as part of the community building process. Brief Description of Services Provided: The Euphrat Museum of Art serves the Cupertino community through it's exhibitions, events, and artist presentations as well as outreach through our Arts& Schools Program, and community involvement with Cupertino festivals and events. As the pandemic has greatly impacted ail in person activities and gatherings this past year, the museum pivoted to offering online exhibitions, presentations, and summer art classes for youth. A public art and poetry project will debut in May 2021 along the perimeter of❑e Anza College facing out towards the community. Art is adaptable to any situation! ION 4: G? 1, ProgramlProjecVEvent Name: Euphrat Museum Exhibitions and Events 2021-2022 2. Date(s)and/or duration of programfprojectlevent (if applicable):2021-2022 exhibitions and events 3. Total program/project/event budget: $196,500 4. Requested Amount: $15.000 Percent of total programlprojectlevent budget: 8% 5, Program/Project projected income: $0 Percentage of your organization'#projected income; 0% B. Type of Request: G Capital Improvement 12 Program Support ❑Event ❑One-time project ❑Other: 7. This grant will fund s(n)- 0 Existing program/projectevent;established in 1970(year) O NewprogrelNprojectevent 8.Describe the purpose of requested funds and the services that will be provided: The funds awarded will go towards 2021 -2022 exhibition and related event expanses.We hope we'll be able to reopen the museum with a new exhibition and (modified)in person visitations in fall.This exhibition, Common Ground, will highlight our shared humanity. In February we plan to present an exhibition curetted in alignment with the 2022 Silicon Valley Reads theme and books and in spring,the De Anna Student Art Show. The exhibitions will feature special installations and free of charge artist presentations open to the public. If we are still Impacted by the pandemic,programming will continue in the virtual space and in public space as creatively possible. 9. Please provide a line hard breakdown of how the funds will be used in the categories below. If a category Is not IC licable, ut$0: Admin Staff $3,000Materials/E ul ment $1,50 Entertainment $ RoomNenue Rental $ Other Professional Services Artist installations $8,00 Other Fine Art Shi in $2,50 tal $15,00 10. Explain how the request aligns to City mission and values: The City is committed to being a model multicultural community Mat appreciates and respects the complexity and richness of our residents. Euphret Museum exhibitions,programs,and events reflect the rich diverse heritage of our area and provide a resource of visual Ideas and a platform for communications among all constituencies.This contributes to Cupertino's ongoing goal of citizen engagement. Though we couldn't participate in City festivals and events or open the museum due to the pandemic,our goal is still to help create a deeper sense of community in Cupertino and draw people together through virtual programming and the themes addressed. 11.Describe how Me program/projectfevent fills a community need.Who Identified this need?What other similar project/programlevenl exists to serve Cupertino residents? How is your proposed projectpmgramlevent unique from similar pmjacts/programs/events or how do you collaborate to avoid duplication? As Cupertino's only ad museum,we serve the Cupertino community through one of a kind exhibitions,events,artist presentations and lectures,outreach through our Ads& Schools Program,and community involvement with City festivals.We also host Cupertino Poet Laureate and other local events when possible. The arts are instrumental in creating a sense of place,fostering a sense of belonging, and preserving collective memory.Supporting culture and creativity is essential for vibrant and sustainable cities like Cupertino.Art is a vital tool for engaging community and articulating our shared values. What Me Euphrat Museum of Art presents is unique in Cupertino(and the Bay Area)and enriches our community. 12,Who will be served by this grant? We serve a wide range of Cupertino citizens and groups of all ages and backgrounds In the museum and In the community. a)Number of individuals total: 18.500 b)Number of Cupertino residents: 9.500 c)Particular community groups: We welcome all community groups to visit our exhibitions and attend events and artist presentations in the museum,in the Cupertino community,online and in person. d)WIII the progrem/proJectevent be available M the entire community/public or are there any eligibility criteria? Exhibitions and related events will be free of charge and open to the entire community/public. a)Will there be a charge or fee for the prograndprujectevent(if applicable) his 1)What outreach methods does your organization use to promote the programlprojecf/avent(if applicable)? •Calendar listings in local newspapers and publicabons • Press releases to solicit articles • De Anum College event calendars and website •Euphret Museum of An website •Constant Contact newsletter • Facebook and other social media • Printed announcements,flyers, and posters 13. Describe how the funds will be used to benefit or impact the Cupertino community: As Cumnino's only an museum,we'll serve the Cupertino community through the exhibitions,events, artist presentations,outreach through the Arts& Schools Program,and community involvement in City festivals if we are able to hold those next year. 14. Demonstrate that the member implementing and managing the program/projacl/event have adequate eniperience: Diana Algebras. Director of the Euphrot Museum of An and Arts&Schools Program, has been with the museum for thirty years. She has received many awards and grants including the CREST award from the City of Cupertino, the Innovation of the Year award from the Foothill De Anza College District, Equity Champion awards,and was nominated for a National Medal in Museum Services.She also received California Arts Council Artist In Residence grants at Cupertino Union School District's lowest Income schools.At De Ann College she has taught Museum Skills Certificate program classes and has been a member of the California Arts Project team. She has presented numerous workshops for artists, classroom teachers,and community organizations including the Mexican Museum and the California Historical Society. Diana is also a studio artist who creates collaborative public an projects and mixed media artworks. She has a B.A. In Studio An from U.C. Santa Cruz and an M.A. In Art and Art Education. 15. How will success of the program/project/event be measured?: Success will be measured by attendance of exhibitions, events,and presentations and enrollments in the Arts& Schools Program. Other criteria will Include visitor and student feedback and evaluations and press and media coverage. 16.Will more than 75%of the requested funds go towards direct service costs versus administrative costs? O Yes O No 17.Will you collaborate with other organizations to deliver the prograrrt/proje illawnl funded by this grant? If so, which organizations? Museum exhibitions and programs also include collaborative artworks by different groups Including Cupertino schools like Homestead High and West Valley Elementary.We Invite participation from a wide range of citizens and groups including the Cupertino Poet Laureate Program, the Cupertino Fine Arts Commission, De Ann College departments,the community-wide program Silicon Valley Reads, and more. 18. If your organization has ever received financial or In-kind support from the City of Cupertino outside of Community Funding Grants, please describe this support: n/a 19. Does your organization anticipate receiving additional financial or in-kind support from the City of Cupertino outside of Community Funding Grants for this type of program/prolecrimvent (e.g.fee waivers)?If so, please describe this anticipated support: nla 20. If you are a mul&jurisdictional organization,describe any funding requested from other agencieslorganizations In regards to this program/project/e rat request. Indicate whether the funding was granted,denied,or is still pending: No 21. How would you fund the program/project/event if you do not receive the requested funding?: We will continue to seek a diverse range of funding including through revenue from Arts&Schools Nation based classes,donations,and local arts grants.Funding from the City of Cupertino Is Important both financially and to help ensure a rich variety of arts and cultural opportunities for the Cupertino community. The pandemic greatly Impacted our Arts&Schools Program and the revenue received from in parson an classes and camps for children and youth. Funds saved from prior years have seen us through this year and are limited. We will continua to apply creativity and resourcefulness in keeping the museum open and responsive to community needs. 1. If you received a Community Funding Grant in prior years, Indicate the amounts for each year and describe how those funds were used: The Museum has received Community Funding Grants for many years,here is an overview of the past 10+years of funding received:2020-2021 $10,000;2019-2020$10,000;201&2019$10,000; 2017-2018$10,000;2016-2017 $10.000;2015-2016$10.000: 2014-2015$10,000;2013-2014 $10,000;2012-2013$10,000;2011-2012$15,000; 2010-2011 $15,000 Each year the funding awarded was used for direct service costs for exhibition related expenses,events, and community outreach and Involvement. 2. If you received a Community Funding Grant last year. a. Please provide a line Item breakdown of how the Community Funding Grant"a used last year in the categories below. if a catemory Is not applicable.out$0: .Admin Staff $2,40 i. Materials/Equipment $4,10 'ii. Entertainment $ v. Rcom ue Nen Rental $ .Other Professional Services $3, I.Other otal $10,00 b.Who was served by the grant last year? The virtual exhibitions and programs,and the May 2021 public art and poetry project are designed to serve Cupertino residents and visitors of all ages. L Number of individuals total: 12,500 I. Number of Cupertino residents:8,750 ill. Particular community groups We aim to serve a variety of community groups of all ages. The attendance numbers for this pandemic year are based on estimated virtual views of exhibitions and programming as well as the estimated number of viewers and participants in the May 2021 public an and poetry project. iv.Was the program/projecthevent available to the entire community/public or are there any eligibility cnterla? Yes. v.Was mere a charge or fee for the program/projecVevent(If applicable)? n/a A.What outreach methods did your organization use to promote the prugram/projectlevent(f applicable)? •Euphrat Museum of Ad website •Constant Contact newsletter •Facetious and other social media •Calendar listings In local newspapers and publications •Press releases W solicit articles •De Anza College event calendars and website c.Wee the program/projert/event successful?Please indicate how success was measured: In pivoting with the pandemic,our programming has been online so far Nis year and has received good virtual attendance,feedback from viewers and participants,and press and media coverage.A major virtual exhibition. Sources of Solace,garnered cover articles in the local community newspapers like Cupertino Courier as wail as online with the Mercury News. This community wide partnership with Silicon Valley Reads,the Santa Clara County Office of Education, and the Santa Clara County Library District has helped expand our audiences and outreach during the pandemic. For example, hie Silicon Valley Reads Kickoff program featured a Sources of Solace slideshow,before and after.The program with the slideshow can be viewed on YouTube and currently has over 2,500 views.The museum also started It's own YouTube channel with recorded programs from this year. 3.Please indicate any additional funding received last year from other sources and provide your financial statement if available: See attached. Attachments:Attach your Inanclal statment, and any other helpful Information about your project. Eyphral Financial Statement for 2D-21.docx Program Manager Signature Director,Euphrat Museum of Art Date Signed 02/01/2021 Euphrat Museum of Art's Income Statement for'fiscal year 2020 — 202I SUPPORT De Anza Associated Student Body grant $89150 Individual Donations/Event Taste of History fundraiser event $14,800 Individual donations $15,200 $30,000 County and City City. of Cupertino $10,000 Subtotal support $4$ 150 REVENUES Arts & Schools Program Fees/Services 2020 De Anza Summer Academy with Community Education Division $.14, 210 Euphrat Museum Enrichment Program at West Valley, Muir, and Collins $0 Cupertino's Quinlan Community Center classes and camps $0 City of Sunnyvale's Columbia Neighborhood Center $0 $149210 Interest/Payout Income $3,250 Subtotal Revenues $17,460 TOTAL INCOME $65,610 I EXPENSES Director's salary $81 500 Part-Time Assistant to the Director's salary $0 Part-Time"Staff Arts & Schools Program Instructors $4200 Dourly Students Student Salaries $850. Benefits Director $33,475 Casual Hourly $125 Student Hourly 40 $33,640 Subtotal Sal"aries + benefits $117,190 Marketing Reception and event refreshments and meals $0 Postage $150 Promotional vinyl signage $0 Announcement postcards and event flyers $0 $150 Exbibition/Production Printing—general $0 May Public Art and Poetry project supplies and materials $4,550 Fine Art and Fed Ex shipping $210 Arts & Schools Program supplies and materials $460 $5,220 Production Services Tech &Prof Services (total) $5,650 Travel $0 Special Projects $4,500 Other Equipment Rent/Lease $0 TOTAL EXPENSES $132,710 EXPENSES OVER REVENUE $679100 I Note: Expenses not covered by revenue are covered by funds saved over the past decade. j These fiends can only cover basic expenses for 2021-22.so we do hope for a pandemic resolution and a return to in person revenue generating programming. I Euphrat Museum (Returning) Eligibility Checklist (staff use oily) E_ligbhi-v YES NO Notes: Be made or sponsored by a 501(c)(3)non-profit organization with experienced members capable of implementing and managing the X program/project/event Identify how the funds will be used to benefit the Cupertino X community X Organization has previously been awarded funds for the requested purpose(most Be awarded only once per project recent funding received FY 2020-21 through Community Funding Grant) For specific needs,not on going,operational costs X Have more than 75%of the requested funds allocated for direct service costs versus administrative costs X .. . Be complete and submitted by the application deadline X Restrictions/Guidelines YES NO Notes: An organization that is applying for multiple grants shall only - submit one application NA Proceeds generated from the funded activity may only be used for the conducted activity NA admission to or participation in the event must be"free of charge"to Cupertino residents unless stated in the application and.approved NA by Parks and Recreation Commission Evaluation Criteria Impact on and benefit Community Need Alignmentwlth Uniqueness of Reasonable Demonstratedeffort Qualifications NEW RETURNING to the Cupertino for the program/ City Mission and the program/ Cost to secure funding /experience APPLICANTS: APPLICANTS: Community project/event Values project/event from her sources of the -How will the organization/ Application Application n 3 - Total#participants -Demonstrated -Exceptional -Unduplicated organization -Non-City funding members Impact Impact p= -#of Cupertino part. community impact Sery ce/ se the gran[ sources or -Cost per resident -Education originality funds -Established -Originality -Past -Availability of event to -Innovation -Level of partnerships with performance ~ ¢ LL the Cupertino -Collaboration collaboration if a other organizations and program Total Community duplicated service efficacies Score NOTES: Mox Points 20 10 15 15 10 10 S S S 100 Organization:Valkyrie Robotics Program/Project/Event:Mini-Robot Competition 0 Organization:Tian Hong Foundation Program/Projezt/Event 2021 youth Art Contest(Nature and Mel 0 Organization:Discovery Counseling Center-Cupertino(DCCC) Program/Project/Event:Afforable Counseling Services 0 Organization:Buddhist Tzu Chi Medical Foundation Program/Project/Event Healthy Cupertino Health Fair 0 Organization:Dhw,ni Academy of Percussion Music in the United States Program/Project/Event:RAGA AND RHYTHM 0 Organization:Kalashree Foundation Inc. Program/Project/.—Indian Classical Music Concert&Workshop Program 0 Organization:Monts Vista High School speech Boosters Inc. Program/Project/Event:Mont,Vista Speech Program 0 Organization:Cupertino Ubrary Foundation Program/Project/Even.Cupertino Library Foundation(CLF)Empower and Connect Seniors Program 0 Organization:APALI Program/Project/Event:APALI youth Leadership Academy 0 Organization:Curriki Program/Project/Event Bringing Cupertino Learning to We 0 Organization:Friends of Deer Hollow Farm Program/Project/Event:Deer Hollow Farm-Demonstration Garden 0 Organization:Santa Clara Valley Audubon Society Program/Projsct/Event Wildlive&Harvest Festival 0 Organization:West Valley Community Services of Santa Clara County,Inc. Program/Project/Event:Gift of Hope Holiday Program 0 Organization:Silicon Valley Jewish Film Festival Program/Project/Event Silicon Valley Jewish Film Festival 0 Organization:Chinese American Coalition for Compassionate Care Program/Project/Event:Starting the Conversation and Mindful self-Care 0 Organization:Rotary Club of Cupertino Program/Project/Event:Cupertino Fall Festival 0 Organization:Euphrat Museum of Art Program/Project/Event:Euphrat Museum Exhib-Rion,and Events 2021-2022 0 Commission Commission Amount Cupertino Status Applicant Caml Mirma SaeM1i NeeaM1a pvemge RaNdng Requested Tier Pmje Name Residents Eligibility Served INew_ValEyrie Robotia $3p00.00 Tier3 Mhti-Robot Competition 40 Eligible INew_Tian Hong Foundation 0 $3,000.00 Tier2 2021Youth Art Contest(Natureand Me) lw Eligible INew_Disrovery Coun gCenter-Cupertino(DCCC) 0 $7,M.00 Tier3 Affordable Counseling Servires 2 Pending INew_Buddhist Tzu Ctd Medical Fowdation $J,400.00 Tier3 Healthy Cupertino Health Fav 40 Eligible INew_Dhward Academy of Percussion Music N the Umted States 0 $9,100.00 Tier, RAGA AND RHYTHM 16 Pnding New_Kalashree Foundation Inca 0 $9,999A0 Tier3 Indian CWssical Music Concert&Workshop Program 100 Eligible (INew_Moms—High School Speech Bao—Inc $13p24.00 Tier4 Monts11h Speech Program 50p00 Pending INew_Cupertino Library Foundation 0 $15,000.00 Tier4 Cupertino Library Foundation(CLF)Empower and Cm Ssiom Program 1. Eligible New�APALI 0 $20,000.W Tier4 APALI Youth Leadership Academy M Eligible C._ $20p00.00 Tier4 Bringing Cupertino Learning[o Life 20,0 Pending Commission Commission Amount Statue Caml Mirma SasM1i Neesfia Average Ranking Requ d Tier Eligibility Last Funded Amaum Funded Pdendsof Deer Hollow Fmm 0 $7,000.00 Tier3 Deer Hollow Farm-Demonetretlon Cardin 12p00 Eligible 120..1 $15,000 White Bam Sam.Ch,a Valley Audubon S M 0 $$,50 W Tier3 Wildlife&Harvest Festival Unknown Pending EY 202.. $7S00 Wildlife&Harvest Day West Valley CommuNty Servlres of Santa Clara County,Inc. 0 $10p00.00 Tier4 C'Rof Hope Holiday Program' 3W Periling FY 2020.2021 $20,000 Building Expansion Silicon Valley Jewish PBm Peetival 0 $10,.R Tier4 SiBcmr Valley Jewish PBm Pestivd 5,000 Periling FY 20262021 $I,—Film Festival Chinese American Coalition for Compassionate Care 0 $12,OOO.00 Tier4 Starling the Conversation and Mindful SelfLa 1,035 Pending EY 202 Ml wwo Smiting the Convesaton Rotary Qu6Ol Cupertino 0 $12,000.M Tim4 CyrperIIm Fall Festival 500 Periling FY 2020-2M1 $12,WC}a,—Fall Festival Euplua[Museum Of Art 0 $15p00.00 —4 Euplua[Museum —1-2822 1500 Periling FY 20.MI $11000.-1,.11&Outreach TOTALCo mItyFundingG.t Requested $1$2,22,.00 `GJt of Hope program fwd dou[of cycle for$5,000 NFY2019-2020 Tiers Tierl �5999.99 Tier2 $11100.00-$4,999.99 Tier3 so wo.00-$9,999.99 Tier4 $10,000.W-$20,000.W C.—ty Funding Approved Funding Range-$MOW to MOD Cupertino Residents Amount Status Applicant Project Name Served Requested Tier Eligibility New__M Valkyrie Robotics Mini-Robot Competition 40 $3,000.00 Tier 2 Eligible Ne�Tian Hong Foundation 2021 Youth Art Contest(Nature and Me) 100 $3,000.00 Tier 2 Eligible Ne�Discovery Counseling Center-Cupertino(DCCC) Affordable Counseling Services 2 $7,200.00 Tier 3 Ne�Buddhist T=Gil Medical Foundation Healthy Cupertino Health Fair 40 $7,400.00 Tier 3 Eligible Ne�Dhwani Academy of percussion Music in the United States RAGA AND RHYTHM 16 $9,100.00 Tier 3 Kalashree Foundation Inc. Indian Classical Music:Concert&Workshop Program 100 $9,9199.00 Tier 3 Eligible Monta Vista High School Speech Boosters Inc Monta Vista Speech Program 50,000 $13,024.00 Tier 4 Ne�Cupertino Library Foundation Cupertino Library Foundation(CLF)Empower and Connect Seniors Program 100 $15,000.00 Tier 4 Eligible Ne�APALI APALI Youth Leadership Academy 20 $20,000.00 Tier 4 Eligible Ne Curriki Bringing Cupertino Learning to Life 20,000 $20,000.00 Tier 4 Cupertino Residents Amount Amount Status Project Name Served Requested Tier Eligibility Last Funded Funded MMAU&a Returning ,Friends of Deer Hollow Farm Deer Hollow Farm-Demonstration Garden 12,000 $7,000.00 Tier 3 Eligible FY 2020-2021 $15,000 White Barn Returnin Santa Clara Valley Audubon Society Wildlife&Harvest Festival Unknown $8,500.00 Tier 3 FY 2020-2021 $7,500 Wildlife&Harvest Day Retumin West Valley Community Services of Santa Clara County,Inc. Gift of Hope Holiday Program* 300 $10,000.00 Tier 4 FY 2020-2021 $20,000 Building Expansion Returnin Silicon Valley Jewish Film Festival Silicon Valley Jewish Film Festival 5,000 $10,000.00 Tier 4 FY 2020-2021 $5,000 Film Festival Returnin Chinese American Coalition for Compassionate Care Starting the Conversation and Mindful Self-Care 1,035 $12,000.00 Tier 4 FY 2020-2021 $6,000 Starting the Conversation Retumin Rotary Gub Of Cupertino Cupertino Fall Festival 500 $12,000.00 Tier 4 FY 2020-2021 $12,000 Cupertino Fall Festival Euphrat Museum Of Art Euphrat Museum Exhibitions and Events 2021-2022 9,500 $15,000.00 Tier 4 FY 2020-2021 $10,000 Exhibits/Events 20-21&Outreach *Gift of Hope program funded out of cycle for$5,000 in FY 2019-2020 Tiers TOTAL Community Funding Grants Requested $182,223.00 Tier 1 <$999.99 Tier 2 $1,000.00-$4,999.99 Tier 3 $5,000.00-$9,999.99 Community Funding Approved Funding Range-$70,000 to$90,000 Tier 4 $10,000.00-$20,000.00 CITY OF CUPERTINO CUPERTINO Legislation Text File M 21-9071, Version: 1 Subject: Commission Initiated Discussion Regarding the Rancho Rinconada Recreation and Park District's Community Outreach Efforts. Discuss Rancho Rinconada Recreation and Park District's Community Outreach Efforts. CITY OF CUPERTINO Page 1 of 1 Printed on 4/1/2021 powered by LegistarTM 0 CITY OF CUPERTINO CUPERTINO Legislation Text File M 21-9072, Version: 1 Sum: Fiscal Year 2021-22 Community Funding Application Evaluations and Recommendation to City Council- Continued. Continuation of Item #3 for the purposes of consideration of evaluations, and decisions to provide funding recommendation for Council. CITY OF CUPERTINO Page 1 of 1 Printed on 4/1/2021 powered by LegistarTM CITY OF PARKS AND RECREATION DEPARTMENT QUINLAN COMMUNITY CENTER 10185 NORTH STELLING ROAD • CUPERTINO, CA 95014-5732 TELEPHONE: (408) 777-3120 • FAX: (408) 777-1305 CUPERTINO CUPERTINO.ORG PARKS AND RECREATION COMMISSION STAFF REPORT Meeting: April 1, 2021 Subject Fiscal Year 2021-22 Community Funding Application Evaluations and Recommendation to City Council—Continued. Recommended Action Continuation of Item #3 for the purposes of consideration of evaluations, and decisions to provide funding recommendation for Council. Discussion Background At the March 4 Parks and Recreation Commission meeting, the 17 applicants for the Fiscal Year (FY) 2021-22 Community Funding Grant Program had the opportunity to attend, provide additional information on their request, and answer any clarifying questions from Commissioners. Prior to the meeting, staff reviewed all submitted applications for completeness and eligibility, determined by compliance to the Community Funding Policy. The Commission was provided with all applications as well as the staff evaluation forms (Attachment A). Evaluation Process At the April 1 regular meeting, the Commission will facilitate the evaluation process and will provide a funding recommendation to City Council. After receiving public comment on the item, there will be a brief recess to allow for the Commissioners to complete their evaluation form (Attachment B) before providing their total out of 100 for each application. Staff will take the totals from each Commissioner and compile them into the evaluation totals form (Attachment C). The Commission will proceed with other business on the agenda to allow staff time to organize the data provided by the Commissioners. When the Commission returns to the item, there will be another opportunity for public comment, specifically regarding evaluations. The Commission will continue to discussion of the data utilizing the evaluation totals form, will have the opportunity to adjust rankings accordingly, and will determine a funding recommendation for City Council. Eligibility Staff concluded that seven applications fully met eligibility requirements and ten applications were pending eligibility, requiring further consideration by the Commission. This is reflected in the Community Funding Applications Summary (Attachment D). Final eligibility of applications will be determined by the Commission during the evaluation process. The Commission will be able to review the scores during the evaluation process and discuss eligibility further as a group. Sustainability Impact No sustainability impact. Fiscal Impact The Commission will review application evaluations and provide a recommendation regarding funding to City Council for final approval. Prepared by: Whitney Zeller, Administrative Assistant Reviewed by: Joanne Magrini, Director of Parks and Recreation Approved for Submission by: Joanne Magrini, Director of Parks and Recreation Attachments: A-Community Funding Applications & Staff Evaluation Forms B-Commissioner Community Funding Evaluation Form C-Evaluation Totals Form D-Community Funding Applications Summary CITY OF CUPERTINO CUPERTINO Legislation Text File#: 21-9073, Version: 1 Subject: Monthly Update Reports. Receive monthly update reports from the Director of Parks and Recreation and commissioners. CITY OF CUPERTINO Page 1 of 1 Printed on 4/1/2021 powered by LegistarTM