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 ο Annual Report (Check √)
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)
How were the funds used by the organization/agency?
List the goals that were achieved by your project:
Community Services Funding Program Page 2
Report Form
Provide a report on how the funds received were expended:
( ) Financial Statement attached ( ) Use Exhibit A Below if necessary
CATEGORY AMOUNT
Salaries & Benefits
Supplies
Facilities & Maintenance
Professional Services
Insurance
Capital Purchases
Other (Please Specify)
Other (Please Specify)
TOTAL
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