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<br />NO Family Nutrition Program <br /> <br />Form A J <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 <br />Family Nutrition Program. Auditing guidelines require that the donor information requested below be kept on <br />file by our project administrators.' Though your gift of time or use of equipment does not represent an actual <br />cash outlay by your organization to the FNP program, it is necessary for us to place a monetary value on that <br />gift, in order to receive an equivalent amount of Federal funding. Please assign dollar values consistent with <br />your 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 />~s, <br />JidvcH k~irl,) (fV"'<kt: - ~ P~'ol;,- ""=IroDI~ <br />L. t <;;}. if i V\ -elr-A.v- r <br />~I~ - L.\l'\iV. j)v. ~.v~.:e. IIID S&>IOa. <br />44(,.,-aRo7 ' <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 , Houriy vallie Estimated hours Total Yearly. <br />(Name and Title) per year to FN P Value <br /> '.' <br />USO- RiVle. ~r+ [;;;S L t V\ c-fy-uL--{o r- ot '-1& :s I II ~Socr,Lj] <br />...1 <br /> .. <br /> . <br /> Total Value <br /> <br />Value of Physical Space (Attach completed and signed "Facilities Space Valuation Worksheet" _ Form 8) and <br />include documentation <br /> <br /> Total Yearly <br /> Value <br />Name of facility <br />Total Value <br /> <br />(over) <br /> <br />C:\wpdocs\forms\contribsp.03 <br />