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<br />NO Family Nutrition Program <br /> <br />Form A <br /> <br />CONTRIBUTOR SUPPORT FORM <br /> <br />October 1, 2003 - September 30, 2004 <br /> <br />Your gift of a donation or service is considered a local match to the Federal dollars that support the Family <br />Nutrition Program. Auditing guidelines require that the donor information requested below be kept on file by our <br />project administrators. Though your gift of time or use of equipment does not represent an actual cash outlay by <br />your organization to the FNP program, it is necessary for us to place a monetary value on that gift, in order to <br />receive an equivalent amount of Federal funding. Please assign dollar values consistent with your <br />company/agency financial records; when in doubt, please assign a conservative estimate. <br />Thank you very much for your gift to our program. It is essential for our continuing operation to have this <br />demonstration of local community support. <br /> <br />County/Site <br />Name of Agency <br />Contact Person <br />Address <br />Phone <br />E-mail <br /> <br />Cass <br />Fargo Public Schools - Jefferson <br />Jerry Stigman <br />315 S 16 St, Fargo <br />701-446-4700 <br /> <br />Value of Personnel Services (Salary + Fringe Benefits) <br /> <br />a <br /> <br />x <br /> <br />b <br /> <br />= <br /> <br />c <br /> <br />Position Hourly value Estimated hours Total Yearly <br />(Name and Title) per year to FNP Value <br />Teachers $49.30 120 $5916.00 <br />Office Staff ( 2 X 5hrs each) $15.49 10 $154.90 <br />Principal $51.51 5 $257.55 <br /> Total Value $6329' .45 <br /> <br />Value of Physical Space (Attach completed and signed "Facilities Space Valuation Worksheet" Form B) and <br />include documentation <br /> <br /> Total Yearly <br /> Value <br />Name of facility <br />Jefferson $1470.96 <br />Total Value $1470.96 <br />