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<br />.... , <br /> <br />NO Family Nutrition Program <br /> <br />,CONTRIBUTOR SUPPORT FORM <br /> <br />APR 2 3 200J <br /> <br />Form A <br /> <br />October 1, 2003 - September 3D, 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 />ft;~~~~tA(~+;:;:~~( ~~.~ <br /> <br />":::;'q~ - /7/ f.,. '. <br />$ba,Ct{tt!ub-f-m. ~rUJ1I"J. ('olY1 <br />. - <br /> <br />Value of Personnel Services (Salary + Fringe Benefits) . .8 <br /> <br />Position Hourly value <br />(Name and Title), <br /> <br />X b <br /> <br /> <br />...... <br /> <br />J1 .q 0 <br /> <br />Estimated hours <br />per year to FNp <br /> <br />= C <br /> <br />Total Yearly <br />Value <br />~6~.OO <br /> <br />Total Value <br /> <br />.pj D. tJ 25 <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 />Total Value . <br /> <br />(over) <br /> <br />C:\wpdocs\forms\contribsp.03 <br />