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<br />-, <br /> <br />NO Family Nutrition Program <br /> <br />,CONTRIBUTOR SUPPORT FORM <br /> <br />APR C) . <br />" ~ 5 2003 <br /> <br />Form A <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 />ii~Jt(!t;:~~AW (~~ <br />~~- ~/q~~ ' <br />. ~ . (d~. /-e,Vl.J.4.: <br /> <br />Value of Personnel Services (Salary + Fringe Benefits) , .8 <br /> <br />Position Houriy value <br />(Name and Title) <br /> <br /> <br />X b = c <br /> Estimated hours Total Yearly <br /> per year to FNp Value <br /> I 5 -2 <br /> <br />Total Value <br /> <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:\wpdoCSlforms\conlribsp.03 <br />