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NON-PROFIT CULTURAL GRANT AGREEMENTNON-PROFIT CULTURAL GRANT AGREEMENT This Non -Profit Cultural Grant or Partnership Agreement ("Agreement") is made as January g , 2024 ("the Effective Date"), by and between THE CITY OF CLEARWATER, a municipal corporation ("City), and CLEARWATER AFRICAN AMERICAN HISTORICAL & MEMORIAL FOUNDATION, INC ("Applicant") (collectively, "Parties"). WITNESSETH: WHEREAS, on March 11, 2021, President Joseph Biden signed into law the American Rescue Plan Act of 2021 ("ARPA"), Pub. L. 117-2, a $1.9 trillion economic stimulus bill passed by the 117th United States Congress to aid the country with the economic and health effects of the COVID-19 pandemic; and WHEREAS, ARPA included a $350 billion Coronavirus State and Local Fiscal Recovery Funds ("SLFRF") program designed to assist state, local, and tribunal governments in their response to the COVID-19 pandemic; and WHEREAS, the City received a total of $22,483,893.00 under the SLFRF program in two equal tranches on May 19, 2021 and June 6, 2022; and WHEREAS, on August 4, 2022, at a duly -noticed City Council meeting, the Clearwater City Council approved funding allocations from the SLFRF program for twelve proposed project and program types; and WHEREAS, one such funding allocation was in the amount of $1,000,000.00 and made for non-profit cultural grants or partnerships ("the Program") which was intended to be used to provide grant funding to nonprofits and government entities for programs focused on arts and cultural opportunities in the community whose programming, services and/or attendance was negatively impacted because of the COVID-19 pandemic; and WHEREAS, on July 20, 2023, the City made available a second round of applications for the Program; and WHEREAS, on September 30, 2023, the City received an application ("the Application") from the Applicant, a true and correct copy of which is attached to this Agreement as Exhibit "A", requesting financial assistance under the program to facilitate, The Remembering Project including historic marker dedication & celebration for descendants of Mack Dixon, and conducting walking and bus tours of the Mack Dixon Subdivision, North Greenwood and North Garden Ave neighborhoods ("the Project"); and WHEREAS, the Application was evaluated and scored by a review committee who recommended approval of the Applicant's financial assistance for the Project request to the Clearwater City Council; and WHEREAS, on December 7, 2023, at a City Council meeting, the Clearwater City Council approved the review committee's recommendation and authorized the City's staff to negotiate a definitive grant agreement with the Applicant; and WHEREAS, the City finds that providing financial assistance for the Project is a permissible expenditure under the Program; and WHEREAS, the City finds that the Project promotes the general public welfare of the citizens of Clearwater; NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, the parties hereby agree as follows: 1 GENERAL 1. Recitals. The foregoing recitals are true and correct and are incorporated in and form a part of this Agreement. 2. Intent; Purpose of Agreement. The purpose of this Agreement is to further the implementation of the Program by providing for financial assistance to the non-profit for programs that focus on arts and culture including programming, targeting organizations that have been negatively impacted due to the COVID-19 pandemic. II. APPLICANT RESPONSIBILITIES 1. Implementation of the Project. The Applicant shall implement the Project in substantial conformity with the Application. 2. Bi -annual Reporting. The Applicant shall submit bi-annual reports accounting for all Program grant funds disbursed to the Applicant and subsequently used by the Applicant for purposes of the Project. Any Program grant funds disbursed by the City but not used by the Applicant by the Termination Date found in Section 9 shall be retumed to the City 14 days after the Termination Date. III. CITY RESPONSIBILITIES 1. Grant Funding. The City shall provide grant funding in the amount of $5,000.00 (five thousand dollars) within 14 days after the Effective Date of this Agreement. 2. City Manager Word Final. The City Manager retains sole discretion to determine whether the Applicant has successfully submitted bi-annual reports as required by Section 11(2) If the City Manager or designee finds the Applicant has not successfully submitted one bi-annual report in compliance with Section 11(2), then the Parties agree that the City Manager's decision is final, this Agreement shall be null and void, the City shall not owe any additional grant money to the Applicant under the Program, the Applicant shall return the initial $5,000.00 originally disbursed to it plus default interest at rate of 10%, and the Applicant shall have no recourse against the City. IV. APPLICANT DEFAULT 1. Failure to Implement the Program. If the Applicant fails to implement the Project in substantial compliance with the Application as required by Section 11(1), then the Parties agree that the Applicant shall be in default under this Agreement. 2. Failure to Submit Bi -Annual Reporting. If the Applicant fails to submit bi-annual reports as required by Section 11(2), then the Parties agree that the Applicant shall be in default under this Agreement. 3. Application Misrepresentations. If the City determines, at any time and in the City's sole discretion, that any portion of the Application constituted a material misrepresentation, then the Parties agree that the Applicant shall be in default under this Agreement. 4. Other Events of Default. In addition to the foregoing, the occurrence of any one or more of the following after the Effective Date shall also constitute an event of default by the Applicant: A. The Applicant shall make a general assignment for the benefit of its creditors, or shall admit in writing its inability to pay its debts as they become due or shall file a petition in bankruptcy, or shall be adjudicated a bankrupt or insolvent, or shall file a petition seeking any reorganization, arrangement, composition, readjustment, liquidation, dissolution or similar relief under any present or future statute, law or regulation or shall file an answer admitting, or shall fail reasonably to contest, the material allegations of a petition filed against it in any such proceeding, or shall seek or consent to or acquiesce in the appointment of any trustee, receiver or liquidator of the Applicant or any material part of such entity's properties; or B. Within 60 days after the commencement of any proceeding by or against the Applicant seeking any reorganization, arrangement, composition, readjustment, liquidation, dissolution or similar relief under any present or future statute, law or regulation, such proceeding shall not have been dismissed or otherwise terminated, or if, within 60 days after the appointment without the consent or acquiescence of the Applicant of any trustee, receiver or liquidator of any of such entities or of any material part of any of such entity's properties, such appointment shall not have been vacated. 5. Notice of Default and Opportunity to Cure. The City shall provide written notice of any default under this Agreement and provide the Applicant 30 days from the date the notice is sent to cure the default. This notice will be deemed sent when sent by first class mail to the Applicant's notice address or when delivered to the Applicant if sent by a different means. 6. Citv Remedies. If, after notice and an opportunity to cure, the Applicant fails to cure any of the events of default listed in Section IV of this Agreement, then the Parties agree that: a) this Agreement shall be null and void; b) that the City will have no further responsibility to the Applicant, including the responsibility to tender any remaining Program grant funds to the Applicant; c) that any Program grant funds actually tendered by the City to the Applicant shall be returned to City along with default interest at a rate of 10% starting from the date of default; and d) the Applicant shall have no recourse against the City. V. MISCELLANEOUS 1. Notices. All notices, demands, requests for approvals or other communications given by either party to another shall be in writing, and shall be sent to the office for each party indicated below and addressed as follows: To the Applicant: Clearwater African American Historical & Memorial Foundation Inc. 2001 World Parkway Blvd Apt 31 Clearwater, FL 33763 Attention: President To the City: City of Clearwater P.O. Box 4748 Clearwater, Florida 33758 Attention: City Clerk with copies to: City of Clearwater P.O. Box 4748 Clearwater, Florida 33758 Attention: City Attorney 2. Unavoidable Delay. Any delay in performance of or inability to perform any obligation under this Agreement (other than an obligation to pay money) due to any event or condition described in this Section as an event of "Unavoidable Delay" shall be excused in the manner provided in this Section. "Unavoidable Delay" means any of the following events or conditions or any combination thereof: acts of God, acts of the public enemy, riot, insurrection, war, pestilence, archaeological excavations required by law, unavailability of materials after timely ordering of same, building moratoria, epidemics, quarantine restrictions, freight embargoes, fire, lightning, hurricanes, earthquakes, tomadoes, floods, extremely abnormal and excessively inclement weather (as indicated by the records of the local weather bureau for a five year period preceding the Effective Date), strikes or labor disturbances, delays due to proceedings under Chapters 73 and 74, Florida Statutes, restoration in connection with any of the foregoing or any other cause beyond the reasonable control of the party performing the obligation in question, including, without limitation, such causes as may arise from the act of the other party to this Agreement, or acts of any governmental authority (except that acts of the City shall not constitute an Unavoidable Delay with respect to performance by the City). An application by any party hereto for an extension of time pursuant to this Section must be in writing, must set forth in detail the reasons and causes of delay, and must be filed with the other party to this Agreement within 30 days following the occurrence of the event or condition causing the Unavoidable Delay or 30 days following the party becoming aware (or with the exercise of reasonable diligence should have become aware) of such occurrence. The party shall be entitled to an extension of time for an Unavoidable Delay only for the number of days of delay due solely to the occurrence of the event or condition causing such Unavoidable Delay and only to the extent that any such occurrence actually delays that party from proceeding with its rights, duties and obligations under this Agreement affected by such occurrence. 3. Indemnification. The Applicant agrees to assume all risks of inherent in this Agreement and all liability therefore, and shall defend, indemnify, and hold harmless the City and the City's officers, agents, and employees from and against any and all claims of loss, liability and damages of whatever nature, to persons and property, including, without limiting the generality of the foregoing, death of any person and loss of the use of any property. This includes, but is not limited to, matters arising out of or claimed to have been caused by or in any manner related to the Applicant's activities or those of any approved or unapproved invitee, contractor, subcontractor, or other person approved, authorized, or permitted by the Applicant whether or not based on negligence. Nothing herein shall be construed as consent by the City to be sued by third parties, or as a waiver or modification of the provisions or limits of Section 768.28, Florida Statutes or the Doctrine of Sovereign Immunity. 4. Assignability; Complete Agreement. This Agreement is non -assignable by either party and constitutes the entire Agreement between the Applicant and the City and all prior or contemporaneous oral and written agreements or representations of any nature with reference to the subject of the agreement are canceled and superseded by the provisions of this agreement. 5. Applicable Law and Construction. The laws of the State of Florida shall govern the validity, performance, and enforcement of this Agreement. This Agreement has been negotiated by the City and the Applicant, and the Agreement, including, without limitation, the Exhibits, shall not be deemed to have been prepared by the City or the Applicant, but by all equally. 6. Severability. Should any section or part of any section of this Agreement be rendered void, invalid, or unenforceable by any court of law, for any reason, such a determination shall not render void, invalid, or unenforceable any other section or any part of any section in this Agreement. 7. Amendments. This Agreement cannot be changed or revised except by written amendment signed by all parties hereto. 8. Jurisdiction and Venue. For purposes of any suit, action or other proceeding arising out of or relating to this Agreement, the parties hereto do acknowledge, consent and agree that venue thereof is Pinellas County, Florida. Each party to this Agreement hereby submits to the jurisdiction of the State of Florida, Pinellas County and the courts thereof and to the jurisdiction of the United States District Court for the Middle District of Florida, for the purposes of any suit, action or other proceeding arising out of or relating to this Agreement and hereby agrees not to assert by way of a motion as a defense or otherwise that such action is brought in an inconvenient forum or that the venue of such action is improper or that the subject matter thereof may not be enforced in or by such courts. If, at any time during the term of this Agreement, the Applicant is not a resident of the State of Florida or has no office, employee, City, registered agent or general partner thereof available for service of process as a resident of the State of Florida, or if any permitted assignee thereof shall be a foreign corporation, partnership or other entity or shall have no officer, employee, agent, or general partner available for service of process in the State of Florida, the Applicant hereby designates the Secretary of State, State of Florida, its agent for the service of process in any court action between it and the City arising out of or relating to this Agreement and such service shall be made as provided by the laws of the State of Florida for service upon a nonresident; provided, however, that at the time of service on the Florida Secretary of State, a copy of such service shall be delivered to the Applicant at the address for notices as provided in Section V(1). 9. Termination. If not earlier terminated as provided in this Agreement, the term of this Agreement shall expire and this Agreement shall no longer be of any force and effect on December 1, 2026. [Remainder of Page Left Blank Intentionally] IN WITNESS WHEREOF, the Parties have caused this Agreement to be signed in its corporate/legal name by its authorized representative or persons authorized to execute this Agreement on the date and year first above written. Clearwater African American Historical and Memorial Foundation Inc. By Barbara J. Sorey-Love President STATE OF FLORIDA ] COUNTY OF PINELLAS ] ac, pi The fore oing instrument was acknowledged before me this day of 2623- by_, S1,.,Sn.t LoNte , who is personally known to me or w has produced a driver's lics as identification. My Commission expires: /aa$ Notary Public THE CITY OF CLEARWATER, a municipal corporation By: J City Manager Attest: �IVIGL�L� 04_,IL en Ko ler Rosemarie Call Lead Assistant City Attorney City Clerk B. General Information Completed by clearwaterafriconamerican@gmail.com on 9/21/2023 2:05 PM Case Id: 15985 Name: Clearwater African American Historical & Address: *No Address Assigned B. General Information Please provide the following information. B.1. Legal Name of Organization (as shown in Line 1 of REPRESENTATIVE CONTACT INFORMATION W-9) Clearwater African American Historical & Memorial 8.10. First Name Foundation, Inc Barbara J. Sorey- B.2. DBA (if applicable — as shown in Line 2 of W-9) 8.11. Last Name Love B.3. Type of Agency 8.12. Title of Position Historical and Cultural Arts President B.4. Physical Address of Organization 8.13. Primary Email 2001 World Parkway Blvd Apt 31 Clearwater, FL 33763 clearwaterafricanamerican@gmail.com B.S. Taxpayer ID (TIN) (if sole proprietorship, enter social security number of sole proprietor) (As shown in Part 1 of W-9) 92-0266842 B.6. Organization Legal Entity Type (as shown in Line 3 of W-9) B.7. Mailing Address for Grant Check (As shown in Line 5 & 6 of W-9) PO Box 4141 Clearwater, FL 33758 B.8. Mission Statement of Organization Mission is to exclusively organize, and shall be managed to celebrate, promote and memorialize Clearwater African American cemeteries, landmarks and buildings within the City of Clearwater and Pinellas County. B.9. Applicant Discipline (select all that apply) Culture Printed By: Amber Brice on 1/8/2024 B.14. Phone Number (727) 485-3137 HNeighborly Software 1 of 2 Er Education ErHistory ElLiterary Arts Q Museum ElPerforming Arts 1ZVisual Arts ❑ Other Printed By: Amber Brice on 1/8/2024 NNeighborly Software C. Project Information Completed by clearwaterafricanamerican@gmaitcom on 9/30/2023 5:17 AM Case Id: 15985 Name: Clearwater African American Historical & Address: *No Address Assigned C. Project Information Please provide the following information. C.1, Project Description Clearwater African American Historical and Memorial Foundation Inc., will establish The Remembering Project. The project will be created specifically to properly remember and honor Clearwater's erased African American cemeteries, landmarks buildings and neighborhoods within the City of Clearwater and Pinellas County.The Remembering Project will collaboratively engage in methods to ensure this happens. C.2. Project Goals m 3 required) 1. The Remembering goal is to recognize the Historic Clearwater Heights aka Mack Dixon Subdivision, one of Clearwater's 1st African American settlements founded in Clearwater, the year 1909. 2. The Remembering Project 's goal is to assist with the planning/design and completion of the memorial for the North Greenwood African American Memoria! Cemetery. 3. The Remembering Pr'ect'sgoa|istnactive|yengageandco||aboratevvithfnrnmerNorthGardenAvenueresidents to identify the people and landmarks who lived in the once self substaning African American community. 4. The Remembering Project's goal is to continue promoting, honoring, collecting artifacts of the history of Pinellas High School and the school Iegacy in North Pinellas County. C.3. Project Activities 1, The Remembering Project will organize a Historic Marker Dedication & Celebration for the Descendants of Mack Dixon, the City of Clearwater and Community stakeholders. The Dedication will be an annual event tp include cultural arts and music. 2.The Remembering Pject's activities will include the Remembering Pject being a sponsor and planner of the bi annual Gala of Pinellas High School and actively participate in the history gathering process of the school and students who went on the become influencers and role models in the City of Clearwater, State of Florida and beyond. 3. The Remembering Project will partner with Pinellas County Schools and the City of Clearwater Chamber to conduct walking and bus tours of the Mack Dixon Subdivision, North Greenwood and North Garden Avenue neighborhoods. C.4. Project Impact — Describe how the program benefits the Clearwatecommunity. The City of Clearwater will benefit by being all inclusive of its' citizens contributions. The completion of these projects will greatly improve the community relations and create a vibrant and welcoming atmosphere for all within the city's African American community and City. This benefit will highlight the rich and diverse contributions of the people ^d families that founded and built Clearwater. Clearwater can proudly represent and be the 'Sparkling City,' which at one time was the city's siogan. C.5. Project Alignment with Cultural Arts Strategic Plan (select one or more of the �� ��l Strengthen the identity of neighborhoods through an investment in pubhc art at the neighborhood level. Printed By: Amber Brice on 1/8/2024 1 of 3 HNeighborly Software RIInvest in iconic public art in strategic locations to bolster the public art experience. • Implement programs that build the capacities of the arts and culture sector to be more unified in their vision toward the same goal. Q Define spaces in Clearwater that an investment in the arts can be concentrated for maximum impact. ErSupport neighborhoods through broadening and diversifying arts experiences. C.6. Project Alignment with Greenprint 2.0 — Describe how the project/program supports the goals and objectives of Clearwater Greenprint 2.0 as it pertains to the following: • Education and Awareness • Green Energy and Buildings • Transportation • Livability • Water Conservation • Waste Reduction • Local Food • Green Economy 1.The Remembering Project goals are to educate and identify these Clearwater communities which many of Clearwater's African Americans lived, were educated and grew up in but native whites and others who lived outside of these communities never knew the neighborhoods existed. As the President of Clearwater African American Historical & Memorial Foundation, Inc., I ask to be included in the project from Ground Zero so that I can educate myself on the options available to make these projects greener and user friendly. 2. Historic Markers will identify and tell the rich history of the community eixistence, buildings and landmarks of the erased African American neigborhoods. Over 90% of the original buildings and schools have been erased. Innovative technologies will need to be introduced to improve the aesthetic's within the city's infrastructure. 3. Mack Dixon, N.Garden Ave and North Greenwood tours can be included and coordinated in the Jolly Trolley routes aka PARK & RIDE. Having this option cuts down on needing emissions therefore protects the environment. The 3 communities are in close proximity to 'Downtown Clearwater' and can be organized as a 'Walking Tour' from specific locations which will also reduce transportation costs and fees. 4. The infrastructure currently has sidewalks; adding/planting trees and shrubs that are seasonal will improve the look and vitality of these green spaces. C.7. Project Evaluation • Describe how you will determine goals of the project are achieved. • Who will conduct the evaluation? • Who or what will the evaluation target? • What methods will be used to collect participant feedback? (surveys, evaluation forms, interviews, etc.) • When will you collect this information? • How will you use this information for future programs? To determine if goals of the project are achieved a outside consulting firm will be hired to assist with the planning. forecasting, implementing. scheduling and evaluation of the written plan vs. the completed work, step by step. Keeping an activity log will determine if goals of the project are achieved. Have an evaluation form, available for participants to rate their experience, interview attendees; Printed By: Amber Brice on 1/8/2024 2 of 3 NNeighborly Software The information will be collected during/after the event/follow up with email survey The information will be used to determine if the event was successful and how to proceed and plan for future events. C.B. Identify the timeline for implementation of the proposed project/program. The Remembering Project is in progress. The projects that I'm currently partipating in as Committee Chairperson with Clearwater African American Cemeteries Memorial Committee and Committee person on A Night at the Library and forming my non-profit Clearwater African American Historical & Memorial Foundation Inc., purposes involve Remembering. C.9. Sustainability — Describe plans to sustain the project/program after grant funds are expended. Recruite Corporate Sponsors, Fund Raise and Apply for other grants. C.10. Routine Maintenance and Utility Costs — If funding is requested for a capital or infrastructure project, provide the anticipated routine maintenance, including utility costs. None. My office space is donated and located at Pinellas High Innovation. C.11. Fiscal Condition — Describe the fiscal condition of your organization as it relates to the successful completion of the project/program proposed. My organization is cash poor :-( C.12. Organization's Fiscal Year December 2022- December 2023 C.13. Organizational Operating Budget Summary Expenses TotafCash Ex 0.00 nc 0.00 Total, Cash Incur $0.00 $0.00 ;ind`Contributio n -Kind Contribution $0.00 $0.00 $0.00 Printed By: Amber Brice on 1/8/2024 3 of 3 H Neighborly Software D. Funding Request Completed by clearwaterafricanamerican@gmail.com on 9/30/2023 5:39 AM Case Id: 15985 Name: Clearwater African American Historical & Address: *No Address Assigned D. Funding Request Please provide the following information. D.1. Funding Request Table Personnel: Administrative $10,400.00 $10,400.00 $0.00 Personnel: Programmatic $5,200.00 $5,200.00 $0.00 Outside Fees and Services: Administrative $5,000.00 $5,000.00 $0.00 Outside Fees and Services: Programmatic $5,000.00 $5,000.00 $0.00 Outside Fees and Services: Other $5,000.00 $5,000.00 $0.00 Space Rental $1,200.00 $1,200.00 $0.00 Marketing $6,000.00 $6,000.00 $0.00 Other $2,200.00 $2,200.00 $0.00 For Projects: Utility Costs $0.00 $0.00 $0.00 $40,000.00 $40,000.00 $0.00 If you selected "Other" please provide expenses in detail D.2. City of Clearwater Cultural Affairs Nonprofit grant funds requested? Note: Allocation of the grant funds will be paid on a case-by-case basis after consulting with awardees their need for the funds. $40,000.00 D.3. Does this project/program anticipate the use of funds or assistance from other organizations? Yes, D.4. Describe your plans to use other funds on this project. In this section, only describe funds that are secured. Provide the source of funds, amounts, and how these funds will be used. NONE Printed By: Amber Brice on 1/8/2024 1111 Neighborly Software 1 of 2 D.S. Describe your plans to seek new funding to supplement ARPA funding. Describe the sources to which you will apply, the amounts sought, and the proposed use of those funds. PINELLAS COUNTY HISTORIC PRESERVATION BOARD - $10,000 PINELLAS COMMUNITY FOUNDATION - $10,000 D.6. What will happen if this project is not funded? If the project is not funded I will continue to volunteer and be an Influenceer in the Clearwater Community. My initial request for funding was denied however I continue to copartner with organizations that have funding to get the work done. D.7. What will happen if this project is partially funded? If the project is partially funded, that is a Blessing. "Some is better than none" a wise woman once said. Printed By: Amber Brice on 1/8/2024 HNeighborly Software 2 of 2 Form -9 (Rev. October 2018) ' Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification ► Go to www.irs.gov/Fom,W9 for instructions and the latest information. Give Form to the requester. Do not. send to the IRS. 1 Name (as on your income tax return). Name is required on this fine; do not leave this line blank Clearwater African American Historical Memorial Foundation, inc 2 Business namefdlsregarded entity name, if different from above 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes. ❑ Individual/sole proprietor or 0 C Corporation 0 s Corporation 0 Partnership 0 Trust/estate sergle-member LLC ❑ Limited liability company. Enter the tax classification (C=C corporation. S4 corporation, P=Partnership) ► Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check LLG if the LLC Is classified as a single -member LLC that Is disregarded from the owner unless the owner of the LLC Is 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. Other (see instructions)► Not For Profit 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from FATCA reporting code (d any) ista w, smantaiedout sfh•tl.S,l 5 Address (number, street, and apt. or suite no.) See instructio PO Box 4141 6 City, state, and ZIP code Clearwater, FL 337584141 Requester's name and address (optional) City of Clearwater Department of Cultural Affairs 7 List account number(s) here (optional) Part 1 Taxpayer identification Number (TiN) Enter your TIN in the appropriate box, The TIN provided must match the name given on line 1 to avoid 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 I, later. For other entities, it is your employer identification number (EN). rf you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Social security number or Employer Identification number 9 2 0 2 6 6 8 4 2 Part I1 Certification Under penalties of perjury, 1 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 1 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, tater. Sign Here Signature of U.S. person ► Date ► General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments rotated to Form W-9 and its instructions, such as legislation enacted after they were published. go to www.irs.govfFormW9. 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 (IN) 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 pnterest eamed 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 1099-9 (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (fioceeds 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) Department of the Treasury internal Revenue Service IRsExempt and Government Entities IR.S P.O. Box 2508 Cincinnati, OH 45201 CLEARWATER AFRICAN AMERICAN HISTORICAL MEMORIAL FOUNDATION INC CIO BARBARA J SOREY-LOVE PO BOX 4141 CLEARWATER, FL 33758 Date: 11/08/2022 Employer ID number: 92-0266842 Person to contact: Name: Customer Service ID number: 31954 Telephone: 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: August 15, 2022 Contribution deductibility: Yes Addendum applies: No DLN: 26053704010552 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 (Foran 990 or Form 990 -EZ) or electronic notice (Form 990-N. the e -Postcard). If you don't tile a required return or notice for three consecutive years. your exempt status will be automatically- revoked. If we indicated at the top of this letter that an addendum applies. the enclosed addendum is an integral part of this letter. For important information about your responsibilities as a tax-exempt organization, go to www.irs.gov/charities. Enter "4221 -PC" in the search bar to view Publication 4221 -PC, Compliance Guide for 501(c)(3) Public Charities, which describes your recordkeeping, reporting, and disclosure requirements. Sincerely. Stephen A. Martin Director. Exempt Organizations Rulings and Agreements Letter 947 (Rev. 2-2020) Catalog Number 35152P 002074 IRS DEPARTMENT ERY INTERNALREVENUESERVICE PHILADELLPHIA PA 19255-0023 002074.463489.191878.3686 1 MB 0.515 920 1IIII1'II'ItdinlitIIIpipipleillI,I.h,IlIIIIII,IIuhllhi CLEARWATER AFRICAN AMERICAN Z BARBARA J SOREY-LOVE 2001 WORLD PARKWAY BLVD APT 31 CLEARWATER FL 33763 X Date of this notice: 09-16-2022 Employer Identification Number: 92-0266842 Forms SS -4 Number of this notices CP 575 C For assistance you may call us at: 1-800-829-4933 IF YOU WRITE, ATTACH THE STUB OF THIS NOTICE. WE—ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER ------ Thank ____-- _Thank you for applying for an Employer Identification Number CEIN), We assigned you EIN 92-0266842. This EIN will identify' your entity, accounts, tax returns, and: documents, -even if you have no employees. Please keep this notice in your permanent records. Taxpayers request an EIN for their business. Some taxpayers receive CP575 notices when another person has stolen their identity and are opening a business using their information. If you did not apply for this EIN, please visit, www.irs.gov/ einnotrequested. When filing tax documents, making payments, or replying to any related correspondence, it is very important that you use your EIN and complete name and address exactly as shown above. Any variation may cause a delay an processing, result in incorrect information in your account, or even cause you to be assigned:more than one EIN. If the information is not correct as shown above, please make the correction using the attached tear -off stub and return it to us. Based on the information received from you or your representative, you must file the following forms by the dates shown. Form 1120 04/15/2023 If you have questions about the forms or the due dates shown, you can call us at the phone number or write to us at the address shown at the top of this notice. If you need help in determining your annual accounting period (tax year), see Publication 538, Accounting Periods and Methods. We assigned you a tax classification (corporation, partnership, etc.) based on information obtained from you or your representative. It is not a legal determination of your tax classification and is not binding of the IRS. If you want a legal determination of your tax classification, you may request a private letter ruling from the IRS under the guidelines in Revenue Procedure 2020-1, 2020-I I,R.8.. 1 (or superseding Revenue Procedure for the year at issue). Note:'Certain tax classification elections can be requested by filing Form 8832, Entity Classification Election. See Farm 8832 and its instructions for additional information.. t219122, 6l1 AL4 M official website of the United States government Here's how }llama SAM.gov Planned Maintenance Show Details s Dec 7, 2022 Entity ValidationTicket Review Show Details Dec 6 2022 ASAM,roor Home Search Data Bank Data Services Help < Get Unique Entity ID 8.440, I ReOsbar Emity LJ I See All Alerts 1 : 1 4 5 6 Get Started Enter Entity Data Start Validation Complete Get Unique Start Validation Entity ID Registration Receive Unique Entity ID Congratulations! You have been assigned the following Unique Entity 10: R25LW2M1N2K9 VERIFIED SAM RECORD CLEARWATER AFRICAN AMERICAN HISTORICAL & MEMORIAL FOUNDATION, INC. 2001 WORLD PARKWAY BLVD #31 CLEARWATER, FL 33763-3633 USA If you now believe you may need to complete a full entity registration, select Continue Registration. Otherwise select Go to Workspace to return to your workspace. Continue Registration Go to Workspace ---- 1 • ARD' CERTIFICATE OF LIABILITY INSURANCE kliew.•-*--' DATE ( 1 023 THIS CERTIFICATE CER11FICATE 15 1SSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(3), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an AODONAL INSURED, the have ADDITIONAL INSUREDs reed. If SUBROGATION IS WANED, subject to the terms and conditions of the poi , certaln poliolesmay requlre a,, endosemsnL A statement on this ceiilfic.te does not confer rights to the certificate holder In lieu of such ). PROOUCER: Next Rrst Insurance Agency. Inc. PO Box 60787 Pato Alto. CA 94306 POLJCY we IMINDIXTYYT1 -55 - 9 9 x* No); MIBRA/S. suPPort@nextInsurance.corn A X (SURA; Next InsuranceUS Company 16285 Clearwater African American Historical & Memorial Foundation, Inc 2001 World Parkway Blvd Apt 31 Clearwater, R. 33763 El : 12/13/2023 ftSURC: EACH OCCURRENCE : DAMAGE TO RENTED WSRE: NSUF: X COVERAGES CERTIFICATE NUMBER: 646507693 REVISION NUMB Ft THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITUSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED 8Y THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ TYPE OF INSURANCE R.XX.V.BR WWI POUCY NUMBER POLJCY we IMINDIXTYYT1 JY UT A X COSINERCIAL GENERAL IJAMIL/TY NXTY9RHYX-00-GL 12/13/2023 12/13/2024 EACH OCCURRENCE ;1,000000.00 DAMAGE TO RENTED 1100.000.00 CIAIMSLLADE X occult PREMISES if -is occunence) MED EXP (My one MEIN $ 10,000,00 PERSONAL & ACV INJURY $1,000,000.00 GENERAL AGGREGATE 11.000,000.00 GENL X AGGREGATE pouvr OTHER: U T PER: LOC pRoouars - CCAIP/OP AGG 51,000,000.00 $ AUTOMOBILE LIANUTY ANY AUTO owNED AUTOS ONLY HIRED AUTOS ONLY — SCHEDULED AUTOS NCI*OWNED AUTOS ONLY if: ABINED SINGLE UNIT $ BCOILY INJURY (Per wpm) 4 BODILY INJURY (Pm oxidant) $ PROPERTY 0AMAGE$ $ UMBRELLA LIAR EXCESS UAL! _ OCCUR CLAIMS4AADE EACH OCCURRENCE 1 AGGREGATE 1 $ CED 1 RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LJASEire Y i N AWROPRETORIPARThER/EXE�ITIVE OFFICERAIFJABEREXCLUDED? Olsodalory In NH) WDETC.RIPTIO140rOPERATION8 below N I A IMTUTE I r EL EACH ACCIDENT $ EL - EA EMPLO?EE 1 El. DISEASE - POUCY LMT 1 A Professional Liability NXTY9RJJYX-00-GL 12/13/2023 1 024 Each Occurrence: Aggregate: $1,000,000.00 $1,000,000.00 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schaddil, may D• alInclud IT mom 'Pada is rPIPPThell Proof of Insurance. Form 1023 (Rev. 12-2017) Name:. EIN: Page 9 Part IX Financial Data For purposes of this schedule, years in existence refer to completed tax years. 1. If in existence less than 5 years, complete the statement for each year in existence and provide projections of your likely revenues and expenlseisbased on a reasonable and good faith estimate of your future finances for a total of (a_ it,� ree years of financi f' formation if you have not completed one tax year, or 8.' -Four years oTfinancial information if you have completed one tax year. See instructions. 2. If in existence 5 or more years, complete the schedule for the most recent 5 tax years. You will need to provide a separate statement that inciudes'information about the most recent 5 tax years because the data table in Part IX has not been updated to.provide for a5th year. See instructions. enses Type of revenue or expense a Current tax year 3 prior tax years or 2 succeeding tax years Provide Total for (e) (a) through (a) through (d) 0 3 m t cc (a) T i� •tf ?To !�iv fb) From % (c) From (d) from i 1, 1 Gifts, grants, and contributions received (do not include unusual grants) x'c'' 23t, , / �� ..4.6"-(1„,jf ' "- t �4 -, .. ` 2 Membership fees received .5ec,C' 1 So '`''' 22 `-'` 'f' 3 Gross investment income ,.--- 4 Net unrelated business income 5 Taxes levied for your benefit I 6 Value of Services or facilities furnished by a governmental unit without charge (riot including the value of'Services generally furnished to the public without charge} (7. 00 IA '6-.C-10 `"�" `'o'> t' / !' 7 Any revenue not otherwise listed above or in lines 9-12 below (attach an itemized fist) 8 Total of lines 1 through 7 `G 7-4.4). ci O7, 2 b 2,i 3c„,4? ( S�1 '.--' 9 Gross receipts from admissions, merchandise sold or services performed, or furnishing of facilities in any activity that is related to your exempt purposes (attach itemized list) ��, - 10 Total of lines 8 and 9 Ire _70C' 3 c;:c- C., 6 7, 3a) J , vt1 f<4 -.' 11 Net gain orloss on sale of capital assets (attach schedule and see instructions) .,--- 12 Unusual grants ----- 13 13 Total Revenue Add lines 10 through 12 L C, v � � � .'`= 7. t....: �:7 L' r 1., ft 3.C.4•4 Yom''' / l e7&j, ,-)> `1..t Expenses 14 Fundraising expenses ju, cx / <_t2) J-=£r,;J /` { ye- &.-y>,. r-: 15 Contributions, gifts, grants,-- and similar amounts paid out (attach an itemized list) "" 16 Disbursements to or for the benefit of members (attach an itemized list) --' "' `' 17 Compensation of officers, directors, and trustees „- ,.?' : _ 18 Other salaries and wages ---'a- 2S ., d'C' 19 Interest expense _.••-'' 20 Occupancy (rent, utilities, etc.) L-4 r -,O C - a > :t Gc o ' t zt , s.t 21 Depredation and depletion E2 Ey 22 Professional fees 4QV ` -' "7Sc '1' C.} 3, 7 '-t�.' 23 Any expense not otherwise classified, sunt as program classified, services (attach itemized list) ,cX) 0-4e.: c\ .-.2."*. 9'2 j' ( 3i-1( 4- ? ( 24 Total Expensesr Add lines 14 through 23 > i E c `t'a 6. 2g" r5r �; i r ° / ,' 1 ((cx,;, r_ o (