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<br />; .....}.;.~ <br /> <br />NO Family Nutrition Program <br /> <br />,CONTRIBUTOR SUPPORT FORM <br /> <br />October 1, 2003 - September 30,2004 <br /> <br />APR 2. 4 (003 <br /> <br />Form A J <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 /> <br />lol- ~Il' "d-C'J4s <br /> <br /> <br />Value of Personnel Services (Salary + Fringe Benefits).8 <br />Hourly value <br />':J.~1 <br />O. <br />I.D'~ <br />:;).. <br />l~.vh <br /> <br /> <br />~dJ <br /> <br />x <br /> <br />b <br /> <br />= <br /> <br />C <br /> <br />Total Yearly <br />Value <br />'Q9 <br />1005 <br />(00$~ <br /> <br />Total Value <br /> <br />~~ - 0, <br /> <br />Value of Physical Space (Attach completed and signed "Facilities Space Valuation Worksheet" _ Form 8) and <br />include documentation <br /> <br />Nam <br /> <br /> <br />, Total Yearly <br />Value <br /> <br />~\\- <br /> <br /> <br /> <br />(over) <br /> <br />Total Value <br /> <br />8t 7 J. - <br /> <br />C:\wpdocs\forms\contribsp .03 <br />