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Donor Name and Title (please print):________________________________
Company Name: _______________________________________________
Mailing Address: _______________________________________________
City: ______________________ State: ______________ Zip: ___________
Contact: _______________________ Phone: ________________________
Please Mark your form of donation:
Date of Donation: ______________________________________________
Monetary: __________________________ IN-Kind: __________________
1. Please list the amount of money to be donated: __________________
2. Please list the nature of the in-kind gift: ________________________
What is the fair market value of the in-kind gift? ____________
How is this market value determined? ____________________
3. Is an income tax receipt requested? ___________________________
*Please note: a new in-kind gift must have a fair market value of at least $25.00 before a tax receipt will be issued. Documentation verifying the value of the gift must be attached to this form. Purchase receipts are acceptable.
Sincerely,
Jennifer Fillmore, MS, CADACIV, ICACII
Treasurer
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