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<br />. <br /> <br />NO Family Nutrition Program <br /> <br />Form A <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 />~5 ..~. <br />/-?? -~~ <br /> <br />Value of Personnel Services (Salary + Fringe Benefits) , .8 <br /> <br />Position Houriy value <br />(Name and Title) <br /> <br />X b = <br /> <br />Estimated hours <br />per year to FN P <br /> <br />c <br /> <br />Total Yearly <br />Value <br /> <br /> <br />Yo <br />z <br />/0 <br /> <br /> <br />Total Value <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 />, <br />Total Value - <br /> <br />(over) <br /> <br />C:lwpdocslforms\contribsp.03 <br />