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CITY of SAN LEANDRO <br /> R E CREATI O N AND HUMAN S E IAV I C E S Official Use Only: <br /> Documents Verified ❑ <br /> Approved: ❑ Denied: ❑ <br /> 1 Approved by: <br /> Initials <br /> �- Date: <br /> CREATI N C0NA M VN ITY <br /> 2015 Hardship Assistance Application <br /> Organization Name: Non-Profit Id # <br /> Organization Contact: ( ) <br /> First Last Email Phone Number <br /> Address: <br /> Street Address City State Zip Code <br /> The purpose of the Hardship Assistance Program (HAP) is to provide reduced field fees to non-profit <br /> organizations serving San Leandro youth. To obtain a one-time adjustment towards field rental fees the <br /> organization must claim a financial hardship for the 2014-15 fiscal year. To determine your eligibility you <br /> are required to submit the completed HAP application and provide any additional information required <br /> to: Lydia Rodriguez, Recreation Supervisor <br /> If your application is approved by the San Leandro Recreation and Human Services Department your <br /> organization will be eligible to receive a 500/o reduction in the 2015 field season up to a maximum of <br /> $3,000.00 per organization per fiscal year. <br /> Application Deadline: March 2, 2015. <br /> Organization Notification of Approval: April 1, 2015 PLEASE CHECK THE THE FOLLOWING: <br /> Yes No <br /> Are you a San Leandro Youth Non-Profit Organization? <br /> Can you provide a valid 501(c)3? <br /> Are you able to provide player rosters to the City of <br /> San Leandro if requested? <br /> Does your organization serve 50% or more San <br /> Leandro youth residents? <br /> The information I have provided in this application is true and correct to the best of my <br /> knowledge. I am aware that this information may be verified by the Federal Government. <br /> Please Note: If all information is not provided, your application may be denied. In the <br /> event that the City of San Leandro Recreation and Human Services Department requests additional <br /> information or verification, I agree to provide such information as required. <br /> Applicant Signature Official Use Only: <br /> Determining Official: <br /> Date: <br /> Date <br />