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<br />.L <br /> <br />~ <br /> <br />'". <br /> <br />NO Family Nutrition Program <br /> <br />Form A <br /> <br />,CONTRIBUTOR SUPPORT FORM <br /> <br />October 1, 2003 - September 301 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 />Eg:~:tr;:,.~ ~:P:: <br /> <br />:241- S-g'{s- . <br /> <br />-S~/IJ ~ <br /> <br />Value of Personnel Services (Salary + Fringe Benefits) .a <br /> <br />Position Hourly value <br />(Name and TitlE!) <br /> <br />.J I.l tJ~t' k <br /> <br />j~ <br /> <br />Tc'/VI O(S <br /> <br /> <br /> <br />X b = c <br /> Estimated hours Total Yearly <br /> per year to FN P Value <br /> f ~ () :; 7S"J. )0 <br /> b ;; ~:;. ~ <br /> <br />Total Value <br /> <br />370 <br /> <br /> <br />(J <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 />