City of Mission Viejo
Recreation & Community Services Department Community Services Funding Program
REPORT FORM
GENERAL INFORMATION Name of Organization _______________________________________________ Phone __________________ Mailing Address ___________________________________________________________ Zip ____________ Contact Person _________________________________ Email Address _______________________________ Funding Received: Fiscal Year ________________ Report for: ο 6-month ORGANIZATION INFORMATION Program/Service Funded _____________________________________________________________________ Amount Received ___________________________ Amount Expended to Date ________________________ Total Number of People Served ___________ Number of Mission Viejo Residents ________________ Time Period _______________________________________________________ (Calendar or Fiscal Year) ο Annual Report (Check √)
How were the funds used by the organization/agency?
List the goals that were achieved by your project:
Community Services Funding Program Report Form
Page 2
Provide a report on how the funds received were expended: ( ) Financial Statement attached ( ) Use Exhibit A Below if necessary
CATEGORY Salaries & Benefits Supplies Facilities & Maintenance Professional Services Insurance Capital Purchases Other (Please Specify) Other (Please Specify) TOTAL
AMOUNT
I hereby certify the information contained in this report is true to the best of my knowledge and belief. I also hereby certify that our organization is in compliance with all state, federal, and local laws regarding licensing and employment practices. _________________________________________________________________________________________
Signature and Title of President or Authorized Officer Date
Return this completed Application to: City of Mission Viejo Recreation & Community Services Department Attn: Leslie Rea-McDonald 200 Civic Center Mission Viejo, California 92691-6301 Office (949) 470-8412 Fax (949) 581-0795 Email Address: lmcdonald@cityofmissionviejo.org