HomeMy WebLinkAbout19 - Community Programs Grants for Fiscal Year 2018/19TO:
FROM
CITY OF
NEWPORT BEACH
City Council Staff Report
November 27, 2018
Agenda Item No. 19
HONORABLE MAYOR AND MEMBERS OF THE CITY COUNCIL
Grace K. Leung, City Manager - 949-644-3001,
gleung@newportbeachca.gov
PREPARED BY: Kim Rieff, Mayor and Council Assistant,
krieff@newportbeachca.gov
PHONE: 949-644-3004
TITLE: Community Programs Grants for Fiscal Year 2018/19
ABSTRACT:
Pursuant to Council Policy A-12, the City of Newport Beach (City) annually awards a
number of Community Programs Grants to local organizations that serve Newport Beach
residents and are beneficial to its residents' quality of life.
RECOMMENDATION:
a) Determine this action is exempt from the California Environmental Quality Act (CEQA)
pursuant to Sections 15060(c)(2) and 15060(c)(3) of the CEQA Guidelines because
this action will not result in a physical change to the environment, directly or indirectly;
b) Pursuant to City Council Policy A-12, find that the organizations listed below provide
services or programs that serve residents and are beneficial to residents' quality of life
and authorize the allocation of $40,000 in Community Programs Grants in the
following manner:
Our Lady Queen of Angels Church — Helping Hands
$8,500
Serving People in Need, Inc. (SPIN)
5,000
Share Our Selves Corporation
5,000
Someone Cares Soup Kitchen
5,000
Boys and Girls Clubs of Central Orange Coast
3,000
Newport -Mesa Family YMCA
3,000
Newport Beach Sister City Association
2,000
Back Bay Therapeutic Riding Club
2,000
Youth Employment Services (YES)
1,500
Amazing Grace Ministries
1,000
Advocates for Grandparent -Grandchild Connection
1,000
Council on Aging
1,000
Speak Up Newport
1,000
Girl Scouts of Orange County
11000
TOTAL
$40,000
19-1
Community Programs Grants for Fiscal Year 2018/19
November 27, 2018
Page 2
c) Allocate $25,000 for the Balboa Island Historical Society and $10,000 for the
Newport Beach Historical Society.
FUNDING REQUIREMENTS:
The current adopted budget includes sufficient funding for the Community Programs
Grants, which will be expensed to the City Council's City Grants budget, Account
01005005-821006.
DISCUSSION:
The City's adopted Fiscal Year 2018/19 General Fund budget and City Council Policy A-
12 Discretionary Grants (Attachment A) set aside $40,000 to provide financial assistance
to organizations providing services to local residents. The operative section of City
Council Policy A-12 provides:
Community Programs Grants shall be expended from the General Fund in the amount of
$40,000 each fiscal year. The City Manager's Office shall review all requests for
Community Programs Grants and shall forward recommendations for funding to the City
Council for final approval. At the time of the City Manager's presentation of any Community
Programs Grant award proposals to the City Council, the City Manager shall show which
entities, if any, have received funds from either the CDBG Social Services Fund or the
District Discretionary Grant Account during the same fiscal year.
The City Manager shall follow these priorities when recommending Community Programs
Grants:
A. Local groups located within the City and offering programs to City residents;
B. Regional groups located in Orange County and offering programs to City
residents; and
C. Groups located in California and offering programs to City residents.
Groups not offering programs or services to local residents shall not be eligible for support
from the City.
In October 2018, an email was sent notifying organizations of the City Council's intent to
award Community Programs Grants for Fiscal Year 2018/19. The information was also
posted on the City's website. Eighteen (18) applications were received.
A staff committee comprised of Library Services Director Tim Hetherton, Lt. Keith
Krallman, Recreation Supervisor Molly Patience, Recreation Supervisor Jennifer Sisoev,
Executive Assistant to the City Manager Shirley Oborny and Mayor and Council Assistant
Kim Rieff reviewed and evaluated each of the 18 applications. The applications were
evaluated based upon how well each fit the priorities referenced above. The applicant
pool was once again highly competitive and the total amount requested was in excess of
the grant funding available. Therefore, the committee is recommending grants for a
majority of applicants that are lower, in some cases significantly, than the funding amount
requested and is not recommending funding for two organizations — Second Chance
Orange County and KOCI Radio. Second Chance has received CDBG funding this year.
19-2
Community Programs Grants for Fiscal Year 2018/19
November 27, 2018
Page 3
At the June 14, 2016 City Council meeting, the City Council voted to increase the amount
budgeted for Community Programs Grants in Fiscal Year 2016/17 by $35,000, reserving
$25,000 for the Balboa Island Historical Society and $10,000 for the Newport Beach
Historical Society. As such, staff budgeted $70,000 for Fiscal Year 2018/19 should the
City Council wish to award the additional $35,000. The Council asked at the time that
these organizations go through an application process concurrent with the Community
Programs Grants process. The City requested and received applications from both
organizations, confirming their eligibility for a grant under this program (Attachments C
and D).
Copies of the submitted applications (and audited financial statements) are on file in the
City Manager's Office, City Hall, 100 Civic Center Drive, Bay E, second floor. A brief
summary of the grant recommendations, including each organization's client base, the
intended uses for the grants, the amount requested by the applicants, and the proposed
funding allocation is included in Attachment B.
ENVIRONMENTAL REVIEW:
Staff recommends the City Council find this action is not subject to the California
Environmental Quality Act (CEQA) pursuant to Sections 15060(c)(2) (the activity will not
result in a direct or reasonably foreseeable indirect physical change in the environment)
and 15060(c)(3) (the activity is not a project as defined in Section 15378) of the CEQA
Guidelines, California Code of Regulations, Title 14, Chapter 3, because it has no
potential for resulting in physical change to the environment, directly or indirectly.
NOTICING:
The agenda item has been noticed according to the Brown Act (72 hours in advance of
the meeting at which the City Council considers the item).
ATTACHMENTS:
Attachment A —City Council Policy A-12
Attachment B — FY 2018-19 Recommended Funding
Attachment C — Balboa Island Museum and Historical Society Grant Application
Attachment D — Newport Beach Historical Society Grant Application
19-3
ATTACHMENT A
A-12
DISCRETIONARY GRANTS
It shall be the policy of the City Council that the City of Newport Beach's ("City")
budget specifically allows the City Council to, at any time during the year, direct
revenue towards worthy projects or programs which the City Council deems beneficial
to Newport Beach's resident's quality of life. The City Council notes that it has multiple
tools at its discretion to assist non-profit agencies, community groups, community
events, or enhancement projects within the City. These tools are:
A. Federal Community Development Block Grant (CDBG) Social Service Funds;
B. Community Programs Grants from the General Fund;
C. Special Event Grants from the General Fund; and
D. The "District Discretionary Grant Account" from the General Fund.
These funds shall be provided for in the following manner:
(CDBG) Social Services funds shall be allocated according to standards set by the
federal government and appropriated at least once each year. The level of funding
offered for social services in Newport Beach shall be based upon federal formulas and
the specific amount of CDBG revenue allocated to the City in any one fiscal year. The
Community Development Department shall administer these funds after City Council
approval of the funds' expenditure.
Community Programs Grants shall be expended from the General Fund in the amount
of $40,000 each fiscal year. The City Manager's Office shall review all requests for
Community Programs Grants and shall forward recommendations for funding to the
City Council for final approval. At the time of the City Manager's presentation of any
Community Programs Grant award proposals to the City Council, the City Manager
shall show which entities, if any, have received funds from the CDBG Social Services
Fund, the District Discretionary Grant Account, or a Special Event Grant during the
same fiscal year.
The City Manager shall follow these priorities when recommending Community
Programs Grants:
A. Local groups located within the City and offering programs to City residents;
1
19-4
A-12
B. Regional groups located in Orange County and offering programs to City
residents; and
C. Groups located in California and offering programs to City residents.
Groups not offering programs or services to local residents shall not be eligible for
support from the City.
Special Events Grants are intended to allow meritorious community, social or athletic
events to offset some or all of their City fees for their event. Doing so should decrease
costs to the event organizer so that beneficiaries can see even greater benefit from any
fundraising associated with the events. The City Manager shall, in consultation with
the City Council, establish a threshold amount for the proposed City budget that
reflects adequate support for these events. The City Manager shall establish an
administrative policy for these grants. The City Manager may divide the funding into
more than one category to ensure that different types of events are fairly measured with
peer events. The City Council shall consider and approve the Special Event Grant
allocations by recipient.
District Discretionary Grant Accounts. At the start of the fiscal year, the City Manager
shall provide an account for each Council District within the City Council's Budget
division known as the District Discretionary Grant Accounts. The City Council shall set
a funding level of these Accounts during the budget process preceding the June
adoption of the City's budget. Each City Council Member shall have, at his or her
discretion, the ability to allocate their District's funding to uses, projects, or community
entities that benefit the City as a whole or the City Council Member's district
specifically. Any expenditure from these Accounts must have an identifiable public
benefit.
Requests to expend these funds should be directed by each City Council Member to the
Finance Director. Expenditures will be reported to the City Council annually. The
report will include a brief description and the public benefit associated with each
expenditure.
At the conclusion of the fiscal year in which the District Discretionary Grant Accounts
received appropriation, all unencumbered funds in the Accounts shall be deposited in
the City's General Fund Reserve Account.
2
19-5
Adopted - July 8,1985
Amended - October 28,1991
Amended - January 24,1994
Amended - May 22, 2001
Amended - June 22, 2010
Amended - September 27, 2011
Amended - May 12, 2015
Formerly F-22
A-12
3
19-6
FY 2018-2019 COMMUNITY PROGRAMS GRANTS Attachment B
Newport Beach City Council - November 27, 2018
# or % of Newport Last CP Recommended in District
Grant Applicant Contact HQ City Client Base Total # of Clients Intended Use of Grant Beach Residents CDBG
Served Grant Rec'd FY 2018-19 Discretionary
1
Our Lady Queen of Angels
Patrick Lauder
Newport
Homeless and low
1,000
Financial help for the
20%
$8,500
$8,500
No
No
Church - Helping Hands
Beach
income
homeless and low income
16 families rental assistance;
rental assistance, food,
Costa
Needy families,
311 families received food; 1
emergency medical and
z
Serving People In Need (SPIN)
Jean Wegener
utilities; 3 motel vouchers; 45
5%
$5,000
$5,000
No
No
Mesa
homeless persons.
gas coupons; 3 bus
dental assistance, move -in
coupons; 298 hygiene items
costs, and care repairs
To purchase food to
3
Share Our Selves (SOS)
Kathleen Bruski
Costa
Food/Grocery Items
5,254
include meats,eggs, milk,
8%
$5,000
$5,000
No
No
Mesa
yogurt, cheese and fresh
fruits and vegetables
4
Someone Cares Soup Kitchen
Shannon
Costa
Anyone that needs
NA
Hunger relief
8%
$5,000
$5,000
No
No
Santos
Mesa
hunger relief
After School Programs,
5
Boys & Girls Club of Central
Travis Whitten
Newport
Youth
300
Day Camps, Athletic
100%
$3,000
$3,000
No
No
Orange Coast
Beach
Leagues, Summer Camps
and Academic Enrichment
After School Programs,
arts and humanities, youth
6
Newport -Mesa Family YMCA
Monique
Newport
Residents of NB
132
sports, aquatics, health and
100%
$3,000
$3,000
No
No
Carpenter
Beach
wellness programs,
volunteer programs and
free special events
Newport Beach Sister City
Suzan Berkley
Newport
Newport Beach
200-300
Cultural Programs and
100 %
$2,000
$2,000
No
No
Association
Beach
Community
educational enhancement
Therapeutic horseback
Back Bay Therapeutic Riding
Bernadette
Newport
riding program for
8
Club
Olsen
Beach
Residents of NB
45
community members with
v
30%
$1,500
$2,000
No
No
disabilities and mental
health challenges
Employment skills training,
Youth Employment Services
Costa
personal finance, money
41 Newport -based youth
9
(YES)
Wendy Weeks
Mesa
Youth ages 16-24
59
management education,
and 11 Newport -based
$1,500
$1,500
No
No
job counseling and job
employers
referrals
10
Amazing Grace Ministries
Judith Kane
Santa Ana
Seniors/nursing
1,872
Amazing Hour Program
N/A
$1,500
$1,000
No
No
home residents
and Program Reguge
Advocates for Grandparent -
Newport
Ongoing Support Groups,
11
Grandchild Connection
Susan Hoffman
Beach
Grandparents
400-500
Education, Books and
50%
$1,000
$1,000
No
No
Films
Bradley
12
Gid Scouts of Orange County
Wedekind-
Irvine
Girl Scouts
299
INSPIRE Program
4%
$0
$1,000
No
No
Flores
Carolina
Seniors 55+ and
Long -Term Care
13
Orange County Council on Aging
Gutierrez-
Santa Ana
their families
10,000
Ombudsman Program,
10%
$3,000
$1,000
No
No
Richau
Health Insurance
Monthly Programs, Mayor's
14
Speak Up Newport
Edward Selich
Newport
NB Residents
1,300
Dinner, NBTV
100%
$0
$1,000
No
No
Beach
Programming
TOTAL = $40,000
19-7
ATTACHMENT C
Balboa Island
museum
NEWPORT BEACH
November 13, 2018
City of Newport Beach
1000 Avocado Avenue
Newport Beach, CA 92660
To Whom It May Concern:
On behalf of the Board of Directors of the Balboa Island Museum, please accept our 2018-2019 City of
Newport Beach Community Programs Grants Application. Enclosed please find:
• The application;
• The most recent financial report (Note: we are on a fiscal year from June 30 to July 1);
• A 2018-2019 budget;
• A current California Statement of Information (Note: we just filed another SOI indicating our
new address and officer);
• A current W-9.
We are excited about our recent move to 210 Marine Avenue, a historic building from the 1920s.
Although the plan to relocate had been in place for some time, the opportunity for this particular
building came as a surprise; hence we have incurred unexpected expenses associated with the move,
many of which are ongoing. However, the good news is that we received a grant for $750,000 to cover
the rent for the next five years (to be dispersed yearly). We knew this was the perfect space in which to
expand the work of the Museum and continue to fulfill our mission: To collect, preserve and promote
the culture and history of Balboa Island and Newport Beach.
Please contact me with any questions.
Warm regards,
Shir ey Pepys V
Pre ident
(949) 466-5531
210 B Marine Avenue . Balboa Island, CA 92662 . (949) 675-3952 . www.balboaislandmuseum.org
.;
t— _
GITY OF NEWPORT i A
Community. • •• a •• • ..or i 19
21
Applicant Information
Name of Applicant Organization: T ,
HF t'I, CLR
Balboa Island Museum and Historical Society r'T/ OF 1�i v,,vow P Nati
Applicant Representative Contact Information:
First Name Shirley Last Name Pepys
Title / Affiliation:
President
Full Address of Organization:
210 Marine Avenue, Balboa Island CA 92662
Phone
Email
949-675-3952
shirley@balboaislandmuseum.org
Type of Entity (indicate one):
Nonprofit (List type) 17Community / Neighborhood School
501(c)(3); 170(b)(1)(A)(vi) Other?
Entity Address (if different from applicant):
Name of Program or Service:
Balboa Island Museum
Type of Program or Service offered to Newport Beach residents:
The only museum showcasing the history of Newport Beach, Balboa Island & communities, and
offering educational programs/presentations to the community and local schools and scouts.
Have you previously received City support for this or a similar program or activity?
YES
NO
❑✓
❑
If yes, please list the programs(s), year(s) and amount(s):
Funds received have been used for various projects including exhibits, development, research,
expansion. 2013 - $15,000; 2014, 2015, 2016 - $20,000; 2017 - $25,000; 2018 - $30,000
Number of Newport Beach residents participating or receiving services within past year. (Specify
numbers by type of service.)
Residents participating in Museum events: Speaker Series, Special Events, etc. = 1,300
Residents visiting the Museum within the past year = 5,000
Percentage of this program devoted or utilized by Newport Beach residents:
75%
19-9
Total annual fundraising/donations/sponsorships received by your organization:
Fiscal Year July 1, 2017 to June 30, 2018: $250,000 in donations; anonymous donation of $150,000
annually for the next 5 years to cover rent in new location.
Brief description of program or activity for which you are seeking a grant:
The New Balboa Island Museum, Newport Beach has expanded! Our new location at 210 Marine Ave.
allows us to more than double our footprint. We have completely redesigned our exhibits to reflect a
state-of-the-art presentation. We will include interactive attractions and more community events. This
prime location will contribute to our growth, greater exposure, and ability to reach more people in our
community, as well as visitors. We desire to be a destination for neighbors and travelers, and a center
point for Newport Beach.
Explain how your program or activity serves, involves or engages Newport Beach residents (150 -
word maximum):
In the past seven years on Marine Ave., the Museum has seen over 100,000 visitors,. many of whom
are Newport Beach residents. They have enjoyed our exhibits while learning about the history of
their communities --Balboa Island, Newport Beach, and Newport Harbor. Residents have raved about
our popular Speaker Events which have celebrated the Newport Beach Police Department, the
Balboa Island Fire Department, the Beek family, Wing Lam & the Lee family, and more. These
events, as well as others, have brought neighbors together in a welcoming environment. The
Museum provides a place where residents can gather. We host the after parties at the Museum for
the BIIA Concert series, the Home Tour & other community events. One year ago we became a
forever home for the John Wayne exhibit, and this year we introduced the Veterans Project,
including an exhibit featuring local veterans and an online database that will allow people to view
first-hand memories of our military. We also have an educational program for Scouts and students.
All of these elements encourage members of our communities to support the City.
The request for City of Newport Beach support must include a list of other City
Yes
No
entities, groups or programs (e.g., CDBG, Discretionary Funds, Special Event
grants, etc.) from which the applicant is seeking financial support. Are you seeking
❑
0
support from other City entities?
If you answered yes above, please list the entities or groups and the amount of financial support
requested from each:
19-10
Amount of financial assistance received last year (FY 17-18) from the City of Newport Beach
(if any): $
$30,000
Amount of financial assistance requested FY 18-19: $
$50,000
A detailed description of how the FY 18-19 grant money would be spent:
Funds from this grant are a wonderful investment in our community. They will be used to continue
the expansion efforts of the newly imagined Museum, which has more square footage for gallery
space, exhibitions, programming, education and events. We have installed a state-of-the-art
audio/visual system and the exhibits have been enhanced and upgraded. This involves a great deal
of design and execution. We desire to offer an unforgettable experience for our community members
and visitors as a community center and destination.
Does your organization work with minor children?
Yes
No
17
If yes, do you require background checks for employees and volunteers?
Y�
No
Please explain:
We offer educational programs for Boy Scouts, Girl Scouts, other children's organizations & local
school children.
19-11
As your organization's representative, please check the box below and type your name in the line
below.
1 acknowledge that submission of this application does not guarantee that my organization
will receive City support.
P
Name: Shirley Pepys
Attach event budget and submit the completed application no later than Friday, November 16, 2018
at 4:30 p.m.
19-12
Balboa Island Museum & Historical society
Profit & Loss
June 2017 through June 12, 2018
Ordinary Income/Expense
Income
41000 • Donations
41100 • Unrestricted- General
41200 • Unrestricted- Major ($2,500+)
41210 • Unrestricted- Grant
41400 • Restricted
Total 41000 • Donations
42000 • Retail Store
42100 • Merchandise Sales
Total 42000 • Retail Store
43000 • Investment Income
43100 - Interest Income
Total 43000 • Investment Income
49000 • Income- Other
49100 - Fundraising Events
49200 - Plaque Sales
49300 • Grants
Total 49000 • Income- Other
Total Income
Cost of Goods Sold
50000 • Cost of Goods Sold
51000 • Purchases
52000 • Labor for Retail Store
53000 • Sales Taxes
Total 50000 • Cost of Goods Sold
Total COGS
Gross Profit
Expense
Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18
�� �� -� r ® lmmw�
707.00
3,405.00
286.00
918.00
2,027.00
13,251.00
9,687.00
0.00
14,867.78
2,500.00
5,300.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
707.00
18,272.78
2,786.00
6,218.00
2,027.00
13,251.00
9,687.00
2,642.60
4,227.15
2,720.40
5,498.40
2,608.10
5,645.88
4,802.47
2,642.60
4,227.15
2,720.40
5,498.40
2,608.10
5,645.88
4,802.47
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
922.72
-661.60
300.00
1,275.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
200.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
922.72
-661.60
300.00
1,275.00
200.00
3,349.60
22,499.93
6,429.12
11,054.80
4,935.10
20,171.88
14,689.47
160.00
294.99
479.00
1,452.41
747.14
2,076.91
2,742.24
0.00
0.00
0.00
0.00
0.00
1,316.50
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
160.00
294.99
479.00
1,452.41
747.14
3,393.41
2,742.24
160.00
294.99
479.00
1,452.41
747.14
3,393.41
2,742.24
3,189.60
22,204.94
5,950.12
9,602.39
4,187.96
16,778.47
11,947.23
Page 1 of 6
19-13
Page 2 of 6
19-14
Jul 17
Aug 17
Sep 17
Oct 17
Nov 17
Dec 17
Jan 18
61000 • FACILITIES
61010 • Rent
4,515.00
4,150.00
4,880.00
4,515.00
4,515.00
4,515.00
4,515.00
61020 • Repairs & Maintenance
100.00
100.00
410.46
700.00
0.00
0.00
0.00
61030 • Insurance
0.00
0.00
207.00
494.00
0.00
861.05
0.00
61050 • Pest Control
0.00
0.00
0.00
0.00
0.00
0.00
189.00
61060 • Utilities
61061 Telephone
0.00
0.00
118.01
0.00
0.00
0.00
0.00
61062 Internet
I
0.00
0.00
0.00
0.00
0.00
59.98
139.97
61063 • Alarm
0.00
127.71
0.00
0.00
0.00
77.85
139.08
61064 • Gas & Electric
0.00
193.90
146.21
176.27
71.83
79.81
7
75.97
Total 61060 • Utilities
0.00
321.61
264.22
176.27
71.83
217.64
�
355.02
Total 61000 • FACILITIES
4,615.00
4,571.61
5,761.68
5,885.27
4,586.83
5,593.69
5,059.02
62000 • LABOR & RELATED
62100 • Payroll Expenses
62110 • Salaries & Wages
2,550.11
2,550.11
1,275.05
50.78
0.00
0.00
0.00
62120 • Payroll Taxes
903.67
903.67
460.84
0.00
0.00
0.00
0.00
62130 • Payroll Service Fee
116.86
116.86
116.86
58.43
0.00
116.86
124.58
Total 62100 • Payroll Expenses
3,570.64
3,570.64
1,852.75
109.21
0.00
116.86
124.58
62200 •Outside Services
62210 • Admin
0.00
920.00
1,000.00
1,230.00
0.00
2,340.00
3,998.00
62220 • Accounting Fees
0.00
0.00
0.00
0.00
0.00
0.00
0.00
62240 • Oral Histories & Interviews
0.00
700.00
700.00
0.00
0.00
0.00
0.00
62250 • Donor Solicitation
0.00
0.00
0.00
0.00
.0.00
0.00
0.00
62200 • Outside Services - Other
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total 62200 • Outside Services
0.00
1,620.00
1,700.00
1,230.00
0.00
2,340.00
3,998.00
Total 62000 • LABOR & RELATED
3,570.64
5,190.64
3,552.75
1,339.21
0.00
2,456.86
4,122.58
63000 • GENERAL & ADMINISTRATIVE
63010 • Bank Fees
144.11
73.84
88.86
178.81
100.85
227.81
99.51
63011 • Merchant Fees
0.00
0.00
0.00
0.00
0.00
0.00
0.00
63020 • Dues & Subscriptions
0.00
82.96
47.00
0.00
352,00
0.00
654.25
63030 • Office Supplies
0.00
458.49
0.00
91.62
130.79
137.17
2,378.23
63040 • Postage
0.00
0.00
0.00
0.00
0.00
0.00
0.00
63090 • Credit Cards
2,637.43
500.00
97.24
2,500.00
130.58
2,873.99
5,087.78
Page 2 of 6
19-14
Page 3 of 6
19-15
Jul
Au- g�
Sep 17
Oct 17
Nov 17
Dec 17
Jan 18
Total 63000 • GENERAL & ADMINISTRATIVE
2,781.54
1,115.29
233.10
2,770.43
714.22
3,238.97
8,219.77
64000 • ADVERTISING & MARKETING
64010 • Printing and Copying
0.00
0.00
0.00
48.79
0.00
0.00
1,937.46
64020 • Historical Home Brochures
0.00
0.00
0.00
0.00
0.00
0.00
0.00
64030 • Graphic Design
0.00
0.00
0.00
0.00
0.00
0.00
0.00
64040 • BIIA Parade
0.00
0.00
0.00
0.00
0.00
0.00
0.00
64050 • Fundraiser Fees
0.00
6,500.00
0.00
0.00
0.00
0.00
0.00
Total 64000 • ADVERTISING & MARKETING
0.00
6,500.00
0.00
48.79
0.00
0.00
1,937.46
Total Expense
10,967.18
17,377.54
9,547.53
10,043.70
5,301.05
11,289.52
19,338.83
Net Ordinary Income
-7,777.58
4,
-3,
-441.31
-1,113.09
5,
-7, 391.60
Other Income/Expense
Other Expense
90100 • Income Taxes
90110 • State Taxes
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total 90100 • Income Taxes
0.00
0.00
0.00
0.00
0.00
0.00
0.00
91100 • Cash Over/(Short)
0.00
0.00
0.00
0.00
0.00
0.00
0.00
91000 • Interest Expense
0.00
0.00
0.00
0.00
0.00
0.00
84.89
99999 • Suspense
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total Other Expense
0.00
0.00
0.00
0.00
0.00
0.00
84.89
Net Other Income
0.00
0.00
0.00
0.00
0.00
0.00
-84.89
Net Income
-7,777.58
4,827.40
-3,597.41
-441.31
-1,113.09
5,488.95
-7,476.49
Page 3 of 6
19-15
Balboa Island Museum & Historical Society
Profit & Loss
June 2017 through June 12, 2018
Ordinary Income/Expense
Income
41000 • Donations
41100 • Unrestricted- General
41200 • Unrestricted- Major ($2,500+)
41210 Unrestricted- Grant
41400 Restricted
Total 41000 • Donations
42000 • Retail Store
42100 • Merchandise Sales
Total 42000 • Retail Store
43000 • Investment Income
43100 • Interest Income
Total 43000 • Investment Income
49000 • Income- Other
49100 • Fundraising Events
49200 • Plaque Sales
49300 • Grants
Total 49000 • Income- Other
Total Income
Cost of Goods Sold
50000 • Cost of Goods Sold
51000 • Purchases
52000 - Labor for Retail Store
53000 • Sales Taxes
Total 50000 • Cost of Goods Sold
Total COGS
Gross Profit
Expense
4:18 PM
06/12/2018
Cash Basis
Feb 18 Mar 18 Apr 18 May 18 Jun 18 TOTAL
mwm� I I I
2,200.00
3,150.00
2,175.00
3,296.55
600.00
41,702.55
0.00
8,000.00
0.00
3,000.00
50,000.00
83,667.78
26,000.00
0.00
0.00
0.00
0.00
26,000.00
2,810.00
0.00
0.00
0. DO
50,000.00
52,810.00
31,010.00
11,150.00
2,175.00
6,296.55
100,600.00
204,180.33
2,775.02
2,839.20
3,594.81
3,409.00
1,081.60
41,844.63
2,775.02
2,839.20
3,594.81
3,409.00
1,081.60
41,844.63
0.02
0.05
0.05
0.05
0.00
0.17
0.02
0.05
0.05
0.05
0.00
0.17
0.00
0.00
0.00
1,663.00
0.00
3,499.12
0.00
0.00
0.00
0.00
0.00
200.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1,663.00
0.00
3,699.12
33,785.04
13,989.25
5,769.86
11,368.60
101,681.60
249,724.25
2,306.63
1,433.41
2,634.69
2,474.55
268.96
17,070.93
1,123.00
1,024.00
960.00
960.00
1,024.00
6,407.50
4,177.00
0.00
0.00
0.00
0.00
4,177.00
7,606.63
2,457.41
3,594.69
3,434.55
1,292.96
27,655.43
7,606.63
2,457.41
3,594.69
3,434.55
1,292.96
27,655.43
26,178.41
11,531.84
2,175.17
7,934.05
100,388.64
222,068.82
Page 4 of 6
19-16
Page 5 of 6
19-17
Feb 18
Mar 18
Apr 18
May 18
Jun 18
TOTAL
61000 • FACILITIES
61010 • Rent
4,515.00
4,515.00
4,515.00
5,020.44
4,767.72
54,938.16
61020 • Repairs & Maintenance
336.00
246.94
270.00
1,420.87
100.00
3,684.27
61030 • Insurance
1,491.55
1,315.00
0.00
-435.00
0.00
3,933.60
61050 • Pest Control
0.00
0.00
189.00
0.00
0.00
378.00
61060 • Utilities
61061 • Telephone
59.98
0.00
272.88
4.99
0.00
455.86
61062 • Internet
25.00
139.97
54.99
58.38
0.00
478.29
61063 • Alarm
77.85
0.00
278.16
116.73
0.00
817.38
61064 • Gas & Electric
174.82
0.00
200.00
0.00
0.00
1,118.81
Total 61060 • Utilities
337.65
139.97
806.03
180.10
0.00
2,870.34
Total 61000 • FACILITIES
6,680.20
6,216.91
5,780.03
6,186.41
4,867.72
65,804.37
62000 • LABOR & RELATED
62100 • Payroll Expenses
62110 • Salaries & Wages
2,416.88
3,597.08
2,381.63
2,158.58
1,209.00
18,189.22
62120 • Payroll Taxes
184.89
275.18
182.20
165.13
92.49
3,168.07
62130 • Payroll Service Fee
61.40
122.80
0.00
122.80
0.00
957.45
Total 62100 • Payroll Expenses
2,663.17
3,995.06
2,563.83
2,446.51
1,301.49
22,314.74
62200 • Outside Services
62210 • Admin
0.00
2,131.08
0.00
0.00
0.00
11,619.08
62220 • Accounting Fees
531.25
1,218.75
3,843.75
0.00
0.00
5,593.75
62240 . Oral Histories & Interviews
0.00
0.00
0.00
0.00
0.00
1,400.00
62250 • Donor Solicitation
0.00
0.00
200.00
0.00
0.00
200.00
62200 • Outside Services - Other
0.00
0.00
0.00
0.00
0.00
0.00
Total 62200 • Outside Services
531.25
3,349.83
4,043.75
0.00
0.00
18,812.83
Total 62000 • LABOR & RELATED
3,194.42
7,344.89
6,607.58
2,446.51
1,301.49
41,127.57
63000 • GENERAL & ADMINISTRATIVE
63010- Bank Fees
21.00
0.00
50.00
15.00
15.00
1,014.79
63011 • Merchant Fees
74.46
101.42
95.61
111.99
22.31
405.79
63020 • Dues & Subscriptions
661.98
50.19
391.86
92.15
1.99
2,334.38
63030 • Office Supplies
46.82
135.08
84.58
56.28
0.00
3,519.06
63040- Postage
0.00
0.00
0.00
461.59
0.00
461.59
63090 • Credit Cards
0.00
0.00
0.00
0.00
0.00
13,827.02
Page 5 of 6
19-17
Page 6 of 6
19-18
Feb 18
Mar 18
Apr 18
May 18
Jun 18
TOTAL
Total 63000 • GENERAL & ADMINISTRATIVE
804.26
286.69
622.05
737.01
39.30
21,562.63
64000 • ADVERTISING & MARKETING
64010 • Printing and Copying
29.19
0.00
0.00
56.03
0.00
2,071.47
64020 • Historical Home Brochures
0.00
0.00
0.00
0.00
0.00
0.00
64030 Graphic Design
0.00
0.00
0.00
250.00
0.00
250.00
64040 BIIA Parade
0.00
0.00
0.00
0.00
0.00
0.00
64050 Fundraiser Fees
0.00
0.00
0.00
744.55
0.00
7,244.55
Total 64000 • ADVERTISING & MARKETING
29.19
0.00
0.00
1,050.58
0.00
Total Expense
10,708.07
13,848.49
13,009.66
10,420.51
6,208.51
138,060.59
Net Ordinary Income
15,470.34
-2,316.65
-10,834.49
-2,486.46
94,180.13
84,008.23
Other Income/Expense
Other Expense
90100 • Income Taxes
90110 • State Taxes
0.00
0.00
0.00
10.00
0.00
10.00
Total 90100 • Income Taxes
0.00
0.00
0.00
10.00
0.00
10.00
91100 • Cash Over/(Short)
0.00
-18.40
0.00
0.00
0.00
-18.40
91000 Interest Expense
0.00
55.03
93.48
88.05
0.00
321.45
99999 Suspense
0.00
0.00
0.00
0.00
0.00
0.00
Total Other Expense
0.00
36.63
93.48
98.05
0.00
313.05
Net Other Income
0.00
-36.63
-93.48
-98.05
0.00
-313.05
Net Income
15,470.34
-2,353.28
-10,927.97
-2,584.51
94,180.13
83,695.18
Page 6 of 6
19-18
2018/2019 Budget
Balboa Island Museum
Fiscal Year Period: July 2018 to June 2019
Income
Donations - General 125,000
Donations - Major 150,000
Grants 180,000
Merchandise Sales - Museum Store) 70,000
Total Income $ 525,000
Expenses
Merchandise (Purchased)
35,000
Administrative Assistance
20,000
Computer
2,500
Dues and Subscriptions
1,000
Graphic Design
10,000
Insurance
3,400
Internet
1,200
New Museum Location (design, tenant
improvements, AIV, security system
installation, labor)
142,000
Payroll Service
1,500
Payroll Taxes
12,000
Postage
1,000
Printing
7,500
Professional & Legal Fees
5,000
Rent
150,000
Repair and Maintenance
3,500
Salaries
100,000
Security System
1,500
Supplies
4,000
Taxes
150
Telephone
1,000
Utilities
1,800
Total Expenses $ 504,050
Net Surplus $ 20,950
19-19
sE,,L OF
Ty
f
P �:' c ..;'p9
�' State of California
`
Secretary of State
09l,cOPP�
Statement of Information
FS16003
(Domestic Nonprofit, Credit Union and General Cooperative Corporations)
FILED
Filing Fee: $20.00. If this is an amendment, see instructions.
IMPORTANT — READ INSTRUCTIONS BEFORE COMPLETING THIS FORM
In the office of the Secretary of State
of the State of California
1. CORPORATE NAME
BALBOA ISLAND MUSEUM AND HISTORICAL SOCIETY
NOV-07 2017
2. CALIFORNIA CORPORATE NUMBER
02180070
This Space for Filing Use Only
_j
Complete Principal Office Address (Do not abbreviate the name of the city. Item 3 cannot be a P.O. Box.)
3. STREET ADDRESS OF PRINCIPAL OFFICE IN CALIFORNIA, IF ANY CITY STATE ZIP CODE
331 MARINE AVENUE, BALBOA ISLAND, CA 92662
4. MAILING ADDRESS OF THE CORPORATION CITY STATE ZIP CODE
SHIRLEY PEPYS 331 MARINE AVENUE, BALBOA ISLAND, CA 92662
Names and Complete Addresses of the Following Officers (The corporation must list these three officers. A comparable title for the specific
officer may be added; however, the preprinted titles on this form must not be altered.)
5. CHIEF EXECUTIVE OFFICER/ ADDRESS CITY STATE ZIP CODE
SHIRLEY PEPYS 331 MARINE AVENUE, BALBOA ISLAND, CA 92662
6. SECRETARY ADDRESS CITY STATE ZIP CODE
JO ELLEN HECK 331 MARINE AVENUE, BALBOA ISLAND, CA 92662
7. CHIEF FINANCIAL OFFICER/ ADDRESS CITY STATE ZIP CODE
JUSTIN ZABILSKI 331 MARINE AVENUE, BALBOA ISLAND, CA 92662
Agent for Service of Process If the agent is an individual, the agent must reside in California and Item 9 must be completed with a California street
address, a P.O. Box address is not acceptable. If the agent is another corporation, the agent must have on file with the California Secretary of State a
certificate pursuant to California Corporations Code section 1505 and Item 9 must be left blank.
8. NAME OF AGENT FOR SERVICE OF PROCESS
SHIRLEY PEPYS
9. STREET ADDRESS OF AGENT FOR SERVICE OF PROCESS IN CALIFORNIA, IF AN INDIVIDUAL CITY STATE ZIP CODE
331 MARINE AVENUE, BALBOA ISLAND, CA 92662
Common Interest Developments
10. F] Check here if the corporation is an association formed to manage a common interest development under the Davis -Stirling Common Interest
Development Act, (California Civil Code section 4000, et seq.) or under the Commercial and Industrial Common Interest Development Act,
(California Civil Code section 6500, et seq.). The corporation must file a Statement by Common Interest Development Association (Form SI -CID) as
required by California Civil Code sections 5405(a) and 6760(a). Please see instructions on the reverse side of this form.
11. THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT.
11/07/2017 JUSTIN ZABILSKI TREASURER
DATE TYPE/PRINT NAME OF PERSON COMPLETING FORM TITLE SIGNATURE
SI -100 (REV 01/2016) APPROVED BY SECRETARY OF STATE
19-20
y."•, Secretary of State
.` SI -100
Statement of Information
o , ; (California Nonprofit, Credit Union and
two General Cooperative Corporations)
IMPORTANT — Ready instructions before completing this form.
Filing Fee — $20.00;
Copy Fees — First page $1.00; each attachment page $0.50;
Certification Fee - $5.00 plus copy fees
1. Corporation Name (Enter the exact name of the corporation as it is recorded with the California
secretary of state)
This Space For Office Use
BALBOA ISLAND MUSEUM AND HISTORICAL SOCIETY ( 2. 7 -Digit Secretary of State File Number
02180070
3. Business Addresses
a Street Address of Cadffomla Principal Office, If any - Do not enter a P.O. Box
210 B MARINE AVENUE
City (no abbreviations)
BALBOA ISLAND
State
CA
Zip Code
92662
b. Mailing Address of Corporation, If different than item 3a
City (no abbreviations)
State
ZIP Code
officers or
Corporation is required to enter the names and addresses of all three of the officers set forth below. An additional title for Chief Executive Officer
or Chief Financial Officer may be added; however, the preprinted Was on this form must not be altered.
a. Chief Executive Officed First Name
Middle Name
last Name
Sum
SHIRLEY
suffix
SHIRLEY
PEPYS
City (no abbreviations)
State
Zip Code
Address
BALBOA ISLAND
City (no abbreviations) -- — —
--State
lip Code
210 B MARINE AVENUE
BALBOA ISLAND
CA
92662
b. Secretary First Name
Middle Name Last Name
Suffix
70 ELLEN
HECK
Address
City (no abbreviations)
State
Zip Code `----
210 B MARINE AVENUE
BALBOA ISLAND
CA
92662
c. Chief Financial Omced Fleet Name
Middle Name Last Nemo
Suffer
BERNADETTE
PETERSON
Address
d..-- -- . _— ------
hY (rro abbrevietiorre) —
-State
- _ - ----- ---
-4—Code
Coda
210 B MARINE AVENUE
BALBOA ISLAND
CA
92662
6. Service of Process (Must provide either individual OR Corporation)
INDIVIDUAL — Complete Items 5a and 5b only. Must include agent's full name and California street address
a. California Agent's First Name (if agent is not a corporation)
Middle Name
Last Name
Sum
SHIRLEY
PEPYS
b. Street Address (if agent is not a corporation) - Do not enter a P.O. Box
City (no abbreviations)
State
Zip Code
210 B MARINE AVENUE
BALBOA ISLAND
C k
92662
I
CORPORATION — Complete item 5o only. Only include the name of the registered acent Comoration.
c. California Registered Corporate Agent's Name (if agent is a corporation) — Do not Complete Item 5a or 5b
o. common interest Lmvelopments
Check here if the corporation is an association formed to manage a common interest development under the Davis -Sterling
`— Common Interest Development Act (California Civil Code section 4000, et seq.) or under the Commercial and Industrial Common
Interest Development Act (California Civil Code section 6500, et seq.). The corporation must file a Statement by Common Interest
Development Association (Form Si -CID) as required by Califnmia Civil Code sections 5405(a) and 6760(a). See Instructions.
r. The Information contained herein, Including in any attachments, is true and correct.
11/13/2018 SHIRLEY PEPYS PRESIDENT -
Date Type or Prim Name of Person Completing the Form Title Signature
SI -100 (REV 0112017)
2017 California Secretary of State
www.sos.ca,govlbusinesslbe
- .. 19-21
Form W=9
(Rev. October 2018)
Department of the Treasury
Internal Revenue Service
cli
m
CL
0
y M
Ci O
ZIv
0
0
d �
CL
N
m
m
on your
2 Business name/disregarded
Request for Taxpayer
Identification Number and Certification
► Go to www
ie tax return). Na
Id Historical
City name, if diffe
for instructions and the latest information.
on this line; do not leave this line
aoove
Give Form to the
requester. Do not
send to the IRS.
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to
following seven boxes. certain entities, not individuals; see
instructions on page 3):
❑ IndividuaVsole proprietor or ❑✓ C Corporation ElS Corporation ElPartnership ❑ Trust/estate
single -member LLC Exempt payee code (if any)
❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ►
Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting
LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is code (if any)
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
U Other (see instructions) 10-
5
5 Address (number, street, and apt. or suite no.) See instructions.
, state, and ZIP code
Ia Island. CA 92
(optionaQ
(Applies to accounts rnVntained outside Me U.S.)
Requester's name and address (optional)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
social security number
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part 1, later. For other
_ m T
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
I Employer identification number
Number To Give the Requester for guidelines on whose number to enter.
F—F-1 i --I I I -I—
EMM01' 13130' EMME
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. 1 am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later.
.Jaye o I Signature of
Here I u.s. person 10./f A..0 -ti jQ Date ► �j �t-c1 . % 3 02
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to wwwJrs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
retums include, but are not limited to, the following.
• Form 1099 -INT (interest earned or paid)
s Form 1099 -DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
ff you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X Form W-9 (Rev. 10-2018)
19-22
Mission
Vision
,sem"
rr`e. new
Balboa Island
museum
NEWPORT BEACH
To collect, preserve and promote the culture and history of Balboa Island and
Newport Beach.
Inspiring our community. A place to gather. Celebrating our heritage.
Museum Organizations & Partnerships
National American Reciprocal Museum (NARM) $100 Member Level
Time Travelers Reciprocal Membership $50 Member Level
American Association for State and Local History (AASLH) Professional
Organization that provides leadership and support.
American Alliance of Museums (AAM) Professional Organization that provides
resources, contacts and support.
Department of Defense Vietnam War Commemoration To Honor Veterans and pay
tribute.
19-23
ATTACHMENT D
NEWPORTCITY OF ►
Community Programs & Human Services Grants Applic-ITion for F"I' 13 19
Applicant Information ZU18 NOY 14 AH 3. 42
Name of Applicant Organization: Oi=FlC�
Newport Beach Historical Society TOF
MS CITY ('k.ERK
Applicant Representative Contact Information: C
First Name Bernie Last Name Svalstad
Title / Affiliation:
President
Full Address of Organization:
1PP4hh52 Sea Ridge Drive Newport Beach, CA 92660
94 M2-7744
p�sva�stad@gmail.com
Type of Entity (indicate one):
Nonprofit (List type) Community /Neighborhood ❑ School ❑
Other? 501 C3
Entity Address (if different from applicant):
Same as applicant.
Name of Program or Service:
Newport Beach Historical Society
-Tvpe of P o am or S ice offe ed t N port Beach residents:
eserve trhe istory o Newport Weac�i,
Have you previously received City support for this or a similar program or activity?
YES
NO
�f0y16//281 eceived �ra�it of'tsa, �r�8r(s) and amount(s):
2017/2018 Received Grant of $10,000
Number of Newport Beach residents participating or receiving services within past year. (Specify
Aumers b� t pe of serv�r
un res f residents o e port Beach and the surrounding areas have visited our website,
museum, and have attended our programs which include speakers at our dinners and programs at
the Newport beach Main Library.
�erentage of this program devoted or utilized by Newport Beach residents:
19-24
Tota �anrUal fundraisirMdongtions/sponsQr�hi s received by your organization:
Mem ers ip, sponsors ips, onations, $1 �3, 0�.
,Qrief des ripati�r�ftprpdgrla or activiny for whicNou are seekin� a c rant:
ewport �e c is on a ociety co ducts ora istory intervie s th our aging citizens in order to
preserve historical memories of Newport Beach. We have completed 10 Oral Histories in 2018 and
anticipate 12-24 additional oral histories in 2019. We continue to incur expenses for archival,
museum improvements and the digitization of newspaper articles and pictures. We also have
worked with the City and the Arts Commission to add additional time line entries into McFadden
Square Centennial Plaza to bring it up to date. We are exploring the opportunity to offer tours to
Newport Beach schools in conjunction with Cube -Quest Tours for the purpose enriching students'
Explain how your program or activity serves, involves or engages Newport Beach residents (150-
lor aximu
ie ewport beach Historical Society involves the citizens of Newport Beach in several ways:
1)capturing the history through oral histories, 2)archival of important historical documents and
pictures, 3)and offering numerous informative programs for citizens to attend and learn about the
history of Newport Beach. We provide dinners, information, and opportunities for volunteer
involvement to help preserve the history of our magnificent City.
The request for City of Newport Beach support must include a list of other City
Yes
No
entities, groups or programs (e.g., CDBG, Discretionary Funds, Special Event
grants, etc.) from which the applicant is seeking financial support. Are you seeking
F
a
support from other City entities?
If you answered yes above, please list the entities or groups and the amount of financial support
requested from each:
19-25
Amount of financial assistance received last year (FY 17-18) from the City of Newport Beach
19-26
As your organization's representative, please check the box below and type your name in the line
below.
FVI I acknowledge that submission of this application does not guarantee that my organization
will receive City support.
Name: Bernie P. Svalstad
Attach event budget and submit the completed application no later than Friday,November 16, 2018
at 4:30 p.m.
19-27
Newport Beach Historical Society
Community Programs Grant Application
11/4/18
To: Mayor and City Council of Newport Beach, CA
Dear Mayor and City Council Members,
Thank you for your continued support of the Newport Beach Historical Society.
We have had a great year as we focused on different aspects of history in
Newport Beach. We started out the Newport Beach Historical Society's Fiftieth
Anniversary celebration in a joint venture with the Boy Scouts. We had an
excellent film presentation of the "Boy Scout Jamboree". This event was
profitable for both the Boy Scouts and the Newport Beach Historical Society. We
followed up with a fun and exciting evening entitled "Taste of History" , which
was held in September and was a dinner program involving 12 local historic
restaurants that participated and served delicious bites at the Balboa Pavilion
Banquet Room. The main speakers at the dinner were the grandchildren of the
McFadden family, whom, as you may recall, were some of the early founders of
Newport Beach. They came all the way from San Diego to help us celebrate this
historic event. As we continued the recognition and celebration of this historic
year for the Newport Beach Historical Society, we produced a program showing
the "Lost Cleopatra" film at the Newport Beach Main Library in March. This was
an epic film that was actually filmed in our Newport Bay. In August we celebrated
the history of the Junior Life Guards at the Oasis Senior Center. This was a family
barbeque event sponsored by T.K. Burgers. Our final event scheduled for 2018 is
scheduled on November 7th and is in conjunction with Visit Newport and the
Newport Beach Chamber of Commerce in presenting "The History of Newport
Beach Boat Parade and Ring of Lights". This fun event will take place at the
historic Balboa Pavilion where we will enjoy a delicious turkey dinner and
presentations by the Beek family, Jeff Parker from the Newport Beach Chamber of
Commerce, and the Newport Beach Historian Howard Hall. As we look ahead to
2019, we have several programs already in the works such as a swing dance, a
Hornblower cruise, and a celebration at the Grand re -opening of the CrabCooker
Restaurant. These are just a few examples of things planned for 2019..
19-28
Newport Beach Historical Society is making a concerted effort to do oral
interviews, as our citizens are aging and we need to preserve important Newport
Beach memories. We have completed 10 oral histories in 2018 and plan to do at
least 12-24 more in 2019. We continue to incur expenses for archival, museum
improvements, and the digitization of Newspaper articles and pictures. We also
have worked with the City and the Arts Commission to add additional time -line
entries into McFadden Square Centennial Plaza, which are now completed.
Another new program being instituted involving the Newport Beach Historical
Society and with cube Quest is the organization of tours from various schools to
come to Newport Beach to enrich their knowledge of the History of Newport
Beach. The Newport Beach Historical Society is requesting $10,000 from the City
of Newport Beach to assist us in preserving the history of Newport Beach. We
have only received $20,000 from the city in the last 50 years. On behalf of the
board of directors, I thank you for your positive consideration.
Sincerely,
Bernie Svalstad
President, Newport Beach Historical Society
19-29
Newport Beach Historical Society
Proposed Budget
July 1, 2018 to June 30, 2019
Ordinary Income/Expense
Income
City Grant
$10,000.00
Auction income
$2,000.00
History of Boat Parade/Dinner
$1,000.00
Jr. Lifeguard program
$1,471.00
Membership dues
$6,000.00
Sponsorships
$5,000.00
Boy Scout movie
$1,594.00
Second Dinner
$2,000.00
Total Income
$29,065.00
Expense
Awards and plaques
$1000.00
Archival expense
$5,000.00
Scout movie
$1,594.00
Accounting fees
$1,000.00
Legal fees
$100.00
Library events
$500.00
Bank service charges
$500.00
Insurance
$500.00
Printing & copying
$2,000.00
Postage & mailing
$500.00
Telephone
$500.00
Website upgrade/maintenance
$500.00
Storage rental
$1,000.00
Contract services
$6,000.00
Office supplies
$300.00
Contingency
$500.00
Facilities & Equipment
Balboa library improvements
$1,000.00
Oral history program
$5,000.00
Total Expense
$27,494.00
Net Income
$1,571.00
19-30
10:38 AM
11/12/18
Cash Basis
Newport Beach Historical Society
Profit & Loss
July through September 2018
Page 1
19-31
Jul - Sep 18
Ordinary Income/Expense
Income
Junior Lifeguard BBQ
1,471.01
Direct Public Support
Individ, Business Contributions
192.00
Direct Public Support - Other
460.00
Total Direct Public Support
652.00
Program Income
Event Donations
30.00
Membership Dues
360.00
Total Program Income
390.00
Total Income
2,513.01
Gross Profit
2,513.01
Expense
Contract Services
2,055.16
Operations
Storage Rental
212.25
Computer & Internet
95.95
Insurance Expense
95.51
Office Supplies
425.66
Printing and Copying
148.33
Total Operations
977.70
Other Types of Expenses
Events
50.00
Total Other Types of Expenses
50.00
Total Expense
3,082.86
Net Ordinary Income
-569.85
Net Income
-569.85
Page 1
19-31
10:37 AM Newport Beach Historical Society
11/12/18 Profit & Loss
Cash Basis July 2017 through June 2018
Ordinary Income/Expense
Income
Direct Public Support
Individ, Business Contributions
Direct Public Support - Other
Total Direct Public Support
Program Income
Event Donations
Membership Dues
Program Income - Other
Total Program Income
Total Income
Gross Profit
Expense
Program Expense
Boy Scouts Movie Presentation
Program Expense - Other
Total Program Expense
Contract Services
Accounting Fees
Contract Services - Other
Total Contract Services
Facilities and Equipment
Equip Rental and Maintenance
Facilities and Equipment - Other
Total Facilities and Equipment
Operations
Storage Rental
Bank Service Charges
Insurance Expense
Office Supplies
Postage, Mailing Service
Printing and Copying
Total Operations
Other Types of Expenses
Events
Other Costs
Total Other Types of Expenses
Total Expense
Net Ordinary Income
Net Income
Jul '17 - Jun 18
25.00
10,003.00
10,028.00
178.50
235.00
17,665.43
18,078.93
28,106.93
28,106.93
1,594.22
35.72
1,629.94
90.00
3,850.00
3,940.00
16.00
770.00
786.00
778.25
296.40
1,025.92
105.43
97.80
207.96
2,511.76
5,028.89
582.06
5,610.95
14,478.65
13,628.28
13,628.28
Page 1
19-32
�. INTERNAL REVENUE SERVICE
P. 0. BOX 2508
CINCINNATI, OH 45201
MAR 112015
Date:
NEWPORT BEACH HISTORICAL SOCIETY
260 NEWPORT CENTER DRIVE SUITE 425
NEWPORT BEACH, CA 92660-0000
DEPARTMENT OF THE TREASURY
Employer Identification Number:
47-3296036
DLN:
26053464001665
Contact Person:
CUSTOMER SERVICE ID# 31954
Contact Telephone Number:
(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:
December 15, 2014
Contribution Deductibility:
Yes
Addendum Applies:
No
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 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 auto...atica-1-ly 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 "4221 -PC" in the search bar
CO view Publication 4221 -PC, Compliance Guide for 501(c)(3) Public Charities,
which describes your recordkeeping, reporting, and disclosure requirements.
Letter 5436
19-33
Page 2 of 2
For filing requirements, refer to FTB Pub. 1068, Exempt Organizations - Filing Requirements and
Filing Fees. Go to ftb.ca.gov and search for 1068.
This exemption is for state franchise or income tax purposes only. For information regarding sates tax
exemption, contact the State Board of Equalization at 800.400.7115 or go to their website at
boe.ca.gov.
Inna M. Bessenyei
Telephone: 916.845.4171
Fax: 916.843.0349
cc: DANIEL DUBOIS CPA
FTB 9944 PASS (REV 12-2014) Exempt Application\Correspondence \LTR
001-EAL
19-34
i, f catiturnie
nchjse Tax Board
PO Box 1286
Rancho Cordova CA 95741-1286
NEWPORT BEACH HISTORICAL SOCIETY
260 NEWPORT CENTER DR STE 425
NEWPORT BEACH CA 92660
Regarding:
Organization's Name:
CCN:
Purpose:
R&TC Section:
Form of Organization:
Accounting Period Ending:
Tax -Exempt Status Effective:
Date: 12.31.15
Case: 26600598262397123
Case Unit: 26600598262397126
In reply refer to: 760:1MB:F190
Tax -Exempt Status
NEWPORT BEACH HISTORICAL SOCIETY
3733913
Charitable
23701d
Incorporated
06/30
12/15/2014
Exempt Acknowledgement Letter
We have received your federal determination letter that shows tax exemption under Internal
Revenue Code (IRC) Section 501(c)(3).
Under California law, Revenue and Taxation Code (R&TC) Section -23701 provides that an
organization is exempt from taxes imposed under Part 11 upon submission of the federal
determination letter approving the organization's tax-exempt status.
Generally, the effective date of an organization's California tax-exempt status is the same date as the
federal tax-exempt status.
To retain tax-exempt status, the organization must be organized and operating for nonprofit
purposes within the provisions of the above R&TC section. An inactive organization is not entitled to
tax-exempt status.
In order for us to determine any effect on the tax-exempt status, the organization must immediately
report to us any change in:
• Operation
• Character
• Purpose
• Name
Address
FTB 9944 PASS (REV 12-2014) Exempt Application\Correspondence \L
001 -FAL
19-35
-2 -
NEWPORT BEACH HISTORICAL SOCIETY
Sincerely,
Director, Exempt Organizations
A
Letter 5436
9-36
19-37
State of California
Secretary of State
C��IFORR�
Statement of Information
FR78643
(Domestic Nonprofit, Credit Union and General Cooperative Corporations)
Filing Fee: $20.00. If this is an amendment, see instructions.
FILED
IMPORTANT — READ INSTRUCTIONS BEFORE COMPLETING THIS FORM
In the office of the Secretary of State
of the State of California
1. CORPORATE NAME
NEWPORT BEACH HISTORICAL SOCIETY
OCT -23 2017
2. CALIFORNIA CORPORATE NUMBER
C3733913
This Space for Filing Use Only
Complete Principal Office Address (Do not abbreviate the name of the city. Item 3 cannot be a P.O. Box.)
3. STREET ADDRESS OF PRINCIPAL OFFICE IN CALIFORNIA, IF ANY CITY STATE ZIP CODE
4. MAILING ADDRESS OF THE CORPORATION CITY STATE ZIP CODE
P.O. BOX 8814, NEWPORT BEACH, CA 92658
Names and Complete Addresses of the Following Officers (The corporation must list these three officers. A comparable title for the specific
officer may be added; however, the preprinted titles on this form must not),e altered.)
5. CHIEF EXECUTIVE OFFICER/ ADDRESS CITY STATE ZIP CODE
BERNIE SVALSTAD 1452 SEA RIDGE, NEWPORT BEACH, CA 92660
6. SECRETARY ADDRESS CITY STATE ZIP CODE
LENARD DAVIS 10 GOODWILL COURT, NEWPORT BEACH, CA 92625
7. CHIEF FINANCIAL OFFICER/ ADDRESS CITY STATE ZIP CODE
JAMES L RUBEL 1412 SANDCASTLE DRIVE, CORONA DEL MAR, CA 92625
Agent for Service of Process If the agent is an individual, the agent must reside in California and Item 9 must be completed with a California street
address, a P.O. Box address is not acceptable. If the agent is another corporation, the agent must have on file with the California Secretary of State a
certificate pursuant to California Corporations Code section 1505 and Item 9 must be left blank.
8. NAME OF AGENT FOR SERVICE OF PROCESSyr .o t. ., ;:grs;is..,.'.
BERNIE SVALSTAD
9. STREET ADDRESS OF AGENT FOR SERVICE OF PROCESS IN CALIFORNIA, IF AN INDIVIDUAL CITY STATE ZIP CODE
1452 SEA RIDGE, NEWPORT BEACH, CA 92660
Common Interest Developments
10. [--1 Check here if the corporation is an association formed to manage a common. interest development under the Davis -Stirling Common Interest
Development Act, (California Civil Code section 4000, et seq.) or under the Commercial and Industrial Common Interest Development Act,
(Califomia Civil Code section 6500, et seq.). The corporation must file a Statement by Common Interest Development Association (Form SI -CID) as
required by California Civil Code sections 5405(a) and 6760(a). Please see instructions on the reverse side of this form.
11. THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT.
10/23/2017 JAMES L RUBEL TREASURER
DATE TYPE/PRINT NAME OF PERSON COMPLETING FORM TITLE SIGNATURE
SI -100 (REV 01/2016) APPROVED BY SECRETARY OF STATE
19-37
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding. For individuals, this is generally your social security number (SHowever, for a — m _
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later. or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Employer identification number
Number To Give the Requester for guidelines on whose number to enter. F-77-1
M
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. 1 am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Sign gnature
Here U.S.person 10- Date
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099 -INT (interest earned or paid)
• Form 1099 -DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X Form W-9 (Rev. 10-2018)
19-38
W-9
Request for Taxpayer
Give Form to the
Form
(Rev. October 2018)
Identification Number and Certification
requester. Do not
Department of the Treasury
send to the IRS.
Internal Revenue Service
► Go to www.irs.gov/FormW9 for instructions and the latest information.
1 Na a (as shown on your income tax return). Name is required on this line; do not,leave this line blank.
2 Business nam /disregarded entity name, if different from above
M
�P
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
Y
4 Exemptions codes apply only to
P� ( PP Y Y
Ca
following seven boxes.
certain entities, not individuals; see
CL
C
❑ Individual/sole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
instructions on page 3):
ai
single -member LLC
Exempt payee code (if any)
CL
❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ►
p 2
Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check
Exemption from FATCA reporting
M
LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is
LLC that is disregarded from
code (if any)
a U
another not the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that
w
is disregarded from the owner should the appropriate box for the tax classification of its owner.
y
/check
her (see instructions) ► l
(Applies to accounts maintained outside the U.S.)
N
5 Address (number, street, and apt. or suite no.) See instructions.
Requester's name and address (optional)
)v7
6 City, state, and ZIP code
We
7 List accounf number(s) here (optional)
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding. For individuals, this is generally your social security number (SHowever, for a — m _
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later. or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Employer identification number
Number To Give the Requester for guidelines on whose number to enter. F-77-1
M
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. 1 am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Sign gnature
Here U.S.person 10- Date
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099 -INT (interest earned or paid)
• Form 1099 -DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X Form W-9 (Rev. 10-2018)
19-38
Foran W-9 (Rev, 12-2014) Paget
Note. If you are a U.S. person and a requester gives you a form other than Form
W-9 to request your TIN, you must use the requester's form it it is substantially
similar to this Foma W-9.
Definition of a U.S. person. For federal tax purposes, you are considered a U.S.
person if you are:
• An individual who is a U.S. citizen or U.S. resident alien;
• A partnership, corporation, company, or association created or organized in the
United States or under the taws of the United States;
• An estate (other than a foreign estate); or
• A domestic trust (as defined in Regulations section 301.7701-7).
Special pries for partnerships. Partnerships that conduct a trade or business in
the United States are generally required to pay a withholding tax under section
1446 on any foreign partners' share of effectively connected taxable income from
such business. Further, in certain cases where a Form W-9 has not been received,
the rules under section 1446 require a partnership to presume that a partner is a
foreign person, and pay the section 1446 withholding tax. Therefore, if you are a
U,S. person that is a partner in a partnership conducting a trade or business In the
United States, provide Fora W-9 to the partnership to establish your U.S. status
and avoid section 1446 withholding on your share of partnership income.
In the cases below, the following person must give Form W-9 to the partnership
for purposes of establishing its U.S. status and avoiding withholding on its
allocable share of net income from the partnership conducting a trade or business
In the United States:
• In the case of a disregarded entity with a U,S. owner, the U.S. owner of the
disregarded entity and not the entity;
• In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally,
the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and
• In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a
grantor trust) and not the temficiaries of the trust -
Foreign person. If you are a foreign person or the U.S. branch of a foreign bank
that has elected to be treated as a U.S. person, do not use Foran W-9, instead, use
the appropriate Form W-8 or Form 8233 (see Publication 515, Withholding of Tax
on Nonresident Aliens and Foreign Entities).
Nonreeklant alien who becomes a resident alien. Generally, only a nonresident
alien individual may use the terms of a tax treaty to reduce or eliminate U.S, tax on
certain types of income. However, most tax treaties contain a provision known as
a "saving clause." Exceptions specified in the saving clause may permit an
exemption from tax to continue for certain types of income even after the payee
has otherwise become a U.S. resident alien for tax purposes.
If you are a U.S, resident alien who Is relying on an exception contained in the
saving clause of a tax treaty to claim an exemption from U.S. tax on certain types
of income, you must attach a statement to Form W-9 that specifies the following
five items:
1. The treaty country. Generally, this must be the same treaty under which you
claimed exemption from tax as a nonresident alien.
2. Tine treaty article addressing the Income.
3. The article number (or location) in the tax treaty that contains the saving
clause and Its exceptions.
4. The type and amount of income that qualities for the exemption from tax.
5. Sufficient facts to justify the exemption from tax under the terms of the treaty
article.
Example. Article 20 of the U.S.-China income tax treaty allows an exemption
from tax for scholarship income received by a Chinese student temporarily present
in the United States. Under U.S. law, this student will become a resident alien for
tax purposes if his or her stay in the United States exceeds 5 calendar years.
However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30,
1984) allows the provisions of Article 20 to continue to apply even after the
Chinese student becomes a resident alien of the United States. A Chinese student
who qualifies for this exception (under paragraph 2 of the first protocol) and is
relying on this exception to claim an exemption from tax on his or her scholarship
or fellowship income would attach to Form W-9 a statement that includes the
information described above to support that exemption.
If you are a nonresident alien or a foreign entity, give the requester the
appropriate completed Form W-8 or Form 8233.
Backup Withholding
What is backup withholding? Persons making certain payments to you must
under certain conditions withhold and pay to the IRS 28% of such payments. This
is called "backup withholding." Payments that may be subject to backup
withholding include interest, tax-exempt Interest, dividends, broker and barter
exchange transactions, rents, royalties, nonemployee pay, payments made in
settlement of payment card and third party network transactions, and certain
payments from fishing boat operators. Real estate transactions are not subject to
backup withholding.
You will not be subject to backup withholding on payments you receive if you
give the requester your correct TIN, make the proper certifications, and report all
your taxable interest and dividends on your tax return.
Payments you receive will be subject to backup withholding if:
1, You do not furnish your TiN to the requester,
2. You do not certify your TIN when required (see the Part It instructions on page
3 for details),
3. The IRS tells the requester that you furnished an incorrect TIN,
4, The IRS tells you that you are subject to backup withholding because you did
not report all your interest and dividends on your tax return (for reportable interest
and dividends only), or
5. You do not certify to the requester that you are not subject to backup
withholding under 4 above (for reportable interest and dividend accounts opened
after 1983 only).
Certain payees and payments are exempt from backup withholding. See Exempt
payee code on page 3 and the separate Instructions for the Requester of Foran
W-9 for more information.
Also see Sped rites for partnerships above.
What is FATCA reporting?
The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign
financial institution to report all United States account holders that are specified
United States persons. Certain payees are exempt from FATCA reporting, Seo
Exer4Wo n from FATCA reporting code on page 3 and the Instructions for the
Requester of Form W-9 for more information.
Updating Your Information
You must provide updated information to any person to whom you claimed to be
an exempt payee if you are no longer an exempt payee and anticipate receiving
reportable payments in the future from this person. For example, you may need to
provide updated Information if you are a C corporation that elects to bean 5
corporation, or if you no longer are tax exempt. In addition, you roust furnish a new
Form W-9 it the name or TIN changes for the account; for example, if the grantor
of a grantor trust dies.
Penalties
Failure to furnish TIN. if you fail to furnish your correct TIN to a requester, you are
subject to a penalty of $50 for each such failure unless your failure is due to
reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding. If you make a
false statement with no reasonable basis that results in no backup withholding,
you are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully falsifying certifications or
affirmations may subject you to criminal penalties including fines and/or
imprisonment.
Misuse of TIN&. If the requester discloses or uses TINs in violation of federal law,
the requester may be subject to civil and criminal penalties.
Specific Instructions
Line 1
You must enter one of the following on this fine; do not leave this line blank. The
name should match the name on your tax return.
If this Form W-9 is for a joint account, list first. and then circle, the name of the
person or entity whose number you entered in Part I of Foram W-9.
a. Ind briduat. GAwwaily, enter the name shown on your tax return. If you have
changed your last name wftirout informing the Social Security Administration (SSA)
of the name change, enter your first name, the last name as shown on your social
security card, and your new last name.
Note. MN applicant- Enter your individual new* as it was entered on your Form
W-7 application, line la: This should also be the same as the name you altered on
the Form 1040h040AI1040EZ you filed with your application.
b. Sole proprietor or &ingWnwmber LLC. Enter your individual name as
shown on your 1040/104OA/I040EZ on line 1. You may enter your business, trade,
or "doing business as" PM) name on line 2.
c. Partnership, LLC that is not a single -member LLC, C Corporation, or S
corporation. Enter the enlity's name as shown on the entity's tax return on line f
and any business, trade, or DBA. name on line 2.
d. other entities, Enter your name as shown on required U.S. federal tax
documents on line 1. This name should match the name shown on the charter or
other legal document creating the entity. You may enter any business, trade, or
DBA name on line 2.
e. Disregarded entity. For U.S. federal tax purposes, an entity that is
disregarded as an entity separate from its owner is treated as a "disregarded
enfity." See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on
line 1. The name of the entity entered on line t should never be a disregarded
entity. The name on line 1 should be the name shown on the income tax return on
which the income should be reported. For example, if a foreign ILLG that is treated
as a disregarded entity for U.S. federal tax purposes has a single owner that Is a
U.S. person, the U.S. owner's name is required to be provided on line 1. If the
direct owner of the entity is also a disregarded entity, enter the first owner that is
not disregarded for federal tax purposes. Enter the disregarded entity's name on
line 2, "Business nameldisregarded entity name." it the owner of the disregarded
entity is a foreign person, the owner must complete an appropriate Form W-8
instead of a Form W-9. This is the case even If the foreign pennon has a U.& TIN.
19-39
Form W-9 (Rev. 10-2018)
Criminal penalty for falsifying information. Willfully falsifying
certifications or affirmations may subject you to criminal penalties
including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of
federal law, the requester may be subject to civil and criminal penalties.
Specific Instructions
Line 1
You must enter one of the following on this line; do not leave this line
blank. The name should match the name on your tax return.
If this Form W-9 is for a joint account (other than an account
maintained by a foreign financial institution (FFI)), list first, and then
circle, the name of the person or entity whose number you entered in
Part I of Form W-9. If you are providing Form W-9 to an FFI to document
a joint account, each holder of the account that is a U.S. person must
provide a Form W-9.
a. Individual. Generally, enter the name shown on your tax return. If
you have changed your last name without informing the Social Security
Administration (SSA) of the name change, enter your first name, the last
name as shown on your social security card, and your new last name.
Note: ITIN applicant: Enter your individual name as it was entered on
your Form W-7 application, line 1 a. This should also be the same as the
name you entered on the Form 1040/1040A/1040EZ you filed with your
application.
b. Sole proprietor or single -member LLC. Enter your individual
name as shown on your 1040/1040A/1040EZ on line 1. You may enter
your business, trade, or "doing business as" (DBA) name on line 2.
c. Partnership, LLC that is not a single -member LLC, C
corporation, or S corporation. Enter the entity's name as shown on the
entity's tax return on line 1 and any business, trade, or DBA name on
line 2.
d. Other entities. Enter your name as shown on required U.S. federal
tax documents on line 1. This name should match the name shown on the
charter or other legal document creating the entity. You may enter any
business, trade, or DBA name on line 2.
e. Disregarded entity. For U.S. federal tax purposes, an entity that is
disregarded as an entity separate from its owner is treated as a
"disregarded entity." See Regulations section 301.7701-2(c)(2)(iii). Enter
the owner's name on line 1. The name of the entity entered on line 1
should never be a disregarded entity. The name on line 1 should be the
name shown on the income tax return on which the income should be
reported. For example, if a foreign LLC that is treated as a disregarded
entity for U.S. federal tax purposes has a single owner that is a U.S.
person, the U.S. owner's name is required to be provided on line 1. If
the direct owner of the entity is also a disregarded entity, enter the first
owner that is not disregarded for federal tax purposes. Enter the
disregarded entity's name on line 2, "Business name/disregarded entity
name." If the owner of the disregarded entity is a foreign person, the
owner must complete an appropriate Form W-8 instead of a Form W-9.
This is the case even if the foreign person has a U.S. TIN.
Line 2
If you have a business name, trade name, DBA name, or disregarded
entity name, you may enter it on line 2.
Line 3
Check the appropriate box on line 3 for the U.S. federal tax
classification of the person whose name is entered on line 1. Check only
one box on line 3.
Page 3
IF the entity/person on line 1 is
THEN check the box for ...
a(n) ..
• Corporation
Corporation
• Individual
Individual/sole proprietor or single-
• Sole proprietorship, or
member LLC
• Single -member limited liability
company (LLC) owned by an
individual and disregarded for U.S.
federal tax purposes.
• LLC treated as a partnership for
Limited liability company and enter
U.S. federal tax purposes,
the appropriate tax classification.
• LLC that has filed Form 8832 or
(P= Partnership; C= C corporation;
2553 to be taxed as a corporation,
or S= S corporation)
or
• LLC that is disregarded as an
entity separate from its owner but
the owner is another LLC that is
not disregarded for U.S. federal tax
purposes.
• Partnership
Partnership
• Trust/estate
Trust/estate
Line 4, Exemptions
If you are exempt from backup withholding and/or FATCA reporting,
enter in the appropriate space on line 4 any code(s) that may apply to
you.
Exempt payee code.
• Generally, individuals (including sole proprietors) are not exempt from
backup withholding.
• Except as provided below, corporations are exempt from backup
withholding for certain payments, including interest and dividends.
• Corporations are not exempt from backup withholding for payments
made in settlement of payment card or third party network transactions.
• Corporations are not exempt from backup withholding with respect to
attorneys' fees or gross proceeds paid to attorneys, and corporations
that provide medical or health care services are not exempt with respect
to payments reportable on Form 1099-MISC.
The following codes identify payees that are exempt from backup
withholding. Enter the appropriate code in the space in line 4.
1—An organization exempt from tax under section 501(a), any IRA, or
a custodial account under section 403(b)(7) if the account satisfies the
requirements of section 401(f)(2)
2—The United States or any of its agencies or instrumentalities
3—A state, the District of Columbia, a U.S. commonwealth or
possession, or any of their political subdivisions or instrumentalities
4—A foreign government or any of its political subdivisions, agencies,
or instrumentalities
5—A corporation
6—A dealer in securities or commodities required to register in the
United States, the District of Columbia, or a U.S. commonwealth or
possession
7—A futures commission merchant registered with the Commodity
Futures Trading Commission
8—A real estate investment trust
9—An entity registered at all times during the tax year under the
Investment Company Act of 1940
10—A common trust fund operated by a bank under section 584(a)
11—A financial institution
12—A middleman known in the investment community as a nominee or
custodian
13—A trust exempt from tax under section 664 or described in section
4947
19-40
Form W-9 (Rev. 10-2018)
1. Interest, dividend, and barter exchange accounts opened
before 1984 and broker accounts considered active during 1983.
You must give your correct TIN, but you do not have to sign the
certification.
2. Interest, dividend, broker, and barter exchange accounts
opened after 1983 and broker accounts considered inactive during
1983. You must sign the certification or backup withholding will apply. If
you are subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2 in the
certification before signing the form.
3. Real estate transactions. You must sign the certification. You may
cross out item 2 of the certification.
4. Other payments. You must give your correct TIN, but you do not
have to sign the certification unless you have been notified that you
have previously given an incorrect TIN. "Other payments" include
payments made in the course of the requester's trade or business for
rents, royalties, goods (other than bills for merchandise), medical and
health care services (including payments to corporations), payments to
a nonemployee for services, payments made in settlement of payment
card and third party network transactions, payments to certain fishing
boat crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of
secured property, cancellation of debt, qualified tuition program
payments (under section 529), ABLE accounts (under section 529A),
IRA, Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your correct
TIN, but you do not have to sign the certification.
What Name and Number To Give the Requester
For this type of account: I Give name and SSN of:
Individual
2. Two or more individuals (joint
account) other than an account
maintained by an FFI
3. Two or more U.S. persons
(joint account maintained by an FFI)
4. Custodial account of a minor
(Uniform Gift to Minors Act)
5. a. The usual revocable savings trust
(grantor is also trustee)
b. So-called trust account that is not
a legal or valid trust under state law
6. Sole proprietorship or disregarded
entity owned by an individual
7. Grantor trust filing under Optional
Form 1099 Filing Method 1 (see
Regulations section 1.671-4(b)(2)(i)
(A))
The individual
The actual owner of the account or, if
combined funds, the first individual on
the account'
Each holder of the account
Page 5
For this type of account: I Give name and EIN of:
14. Account with the Department of The public entity
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
15. Grantor trust filing under the Form The trust
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulations section 1.671-4(b)(2)(i)(B))
' List first and circle the name of the person whose number you furnish.
If only one person on a joint account has an SSN, that person's number
must be furnished.
2 Circle the minor's name and furnish the minor's SSN.
3 You must show your individual name and you may also enter your
business or DBA name on the "Business name/disregarded entity"
name line. You may use either your SSN or EIN (if you have one), but the
IRS encourages you to use your SSN.
List first and circle the name of the trust, estate, or pension trust. (Do
not furnish the TIN of the personal representative or trustee unless the
legal entity itself is not designated in the account title.) Also see Special
rules for partnerships, earlier.
*Note: The grantor also must provide a Form W-9 to trustee of trust.
Note: If no name is circled when more than one name is listed, the
number will be considered to be that of the first name listed.
Secure Your Tax Records From Identity Theft
Identity theft occurs when someone uses your personal information
such as your name, SSN, or other identifying information, without your
permission, to commit fraud or other crimes. An identity thief may use
your SSN to get a job or may file a tax return using your SSN to receive
a refund.
To reduce your risk:
• Protect your SSN,
The minor2 • Ensure your employer is protecting your SSN, and
• Be careful when choosing a tax preparer.
The grantor -trustee' If your tax records are affected by identity theft and you receive a
The actual owner' notice from the IRS, respond right away to the name and phone number
printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you
The owner 3 think you are at risk due to a lost or stolen purse or wallet, questionable
credit card activity or credit report, contact the IRS Identity Theft Hotline
The grantor* at 1-800-908-4490 or submit Form 14039.
For this type of account: I Give name and EIN of:
8. Disregarded entity not owned by an
individual
9. A valid trust, estate, or pension trust
10. Corporation or LLC electing
corporate status on Form 8832 or
Form 2553
11. Association, club, religious,
charitable, educational, or other tax-
exempt organization
12. Partnership or multi -member LLC
13. A broker or registered nominee
I he owner
I Legal entity'
For more information, see Pub. 5027, Identity Theft Information for
Taxpayers.
Victims of identity theft who are experiencing economic harm or a
systemic problem, or are seeking help in resolving tax problems that
have not been resolved through normal channels, may be eligible for
Taxpayer Advocate Service (TAS) assistance. You can reach TAS by
calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD
1-800-829-4059.
The corporation Protect yourself from suspicious emails or phishing schemes.
Phishing is the creation and use of email and websites designed to
mimic legitimate business emails and websites. The most common act
The organization is sending an email to a user falsely claiming to be an established
legitimate enterprise in an attempt to scam the user into surrendering
private information that will be used for identity theft.
The partnership
The broker or nominee
19-41